TOKIO MARINE
HCC
Specialty Group
401 Edgewater Place, Suite 400
Wakefield, MA 01880 USA
Tel: 781-994-6000 Fax: 781-994-6001
INCIDENT REPORT
To be completed by Insured for insurance records.
Incident Only
Claim
Team Name:
*
Athlete Name:
*
Athlete Jersey # or indicate Cheer :
*
Team Level (Mascots, Freshman, JV, Varsity) :
*
League Name:
Policy Name:
Policy #:
Insured Contact:
Phone:
Format: (000) 000-0000.
Address:
Email:
example@example.com
INCIDENT:
Date of Incident:
-
Month
-
Day
Year
Date
Time of Day:
Hour Minutes
AM
PM
AM/PM Option
Area Accident Occurred:
Condition of Area:
Is There Video of that Area? Yes / No
Yes
No
has video been saved/copied? Yes/ No
Yes
No
How did Incident Happen? / Accident Description:
A member of the Tokio Marine HCC group of companies
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TOKIO MARINE
HCC
Report.
Witnesses: Name/Address/Phone:
Officials/Coaches with knowledge of Incident: Name/Phone:
Comments / Notes:
If possible, it is always helpful to get photos of the area involved and/or the injury.
If any video exists, please save a copy immediately so it is not erased from the system.
Accident reports along with Waivers can be emailed to American Claims Management at :
NewLosses@acmclaims.com. You can also reach American Claims Management by telephone at 1-
888-799-2919.
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