GSCI Accident Form
Fill in the following information about the injured person and incident. When medical treatment has been sought please complete the Mutual of Omaha Claim form, located at the bottom of this form, as well as the email you will receive upon completion of this form.
Injured Person Name:
*
First Name
Last Name
Name of caregiver (if injured person is a minor)
First Name
Last Name
Email of injured person or caregiver
*
example@example.com
Phone Number of injured person or caregiver
*
Please enter a valid phone number.
Birthdate of injured person
-
Month
-
Day
Year
Date
Address of injured person
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Accident
-
Month
-
Day
Year
Date
Time of accident
Hour Minutes
AM
PM
AM/PM Option
Location where accident occured:
Address of accident:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Activity engaged in at the time of the accident:
Describe the details of how the accident occured:
What treatment or steps were taken after the accident/injury?
First Aid was applied by:
First Name
Last Name
Witness Information
Provide information for responsible witnesses (adults who were present at scene)
Witness #1
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Witness #2
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Witness #3
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Treatment Facility Information
Give name of facility or hospital injured person was taken to for medial assistance. Keep in mind if there is an urgent care closer than the hospital emergency room, they should be taken there. If patient is in a crisis situation, the emergency room may be better.
Name of Medical Facility
Address of Medical Facility
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name of Doctor or attendant seeing injured person:
First Name
Last Name
Name of Staff member completing form:
First Name
Last Name
Email of staff completing form:
example@example.com
Phone Number of staff completing form:
Please enter a valid phone number.
Submit
Should be Empty: