This Form Completed By

FREESTYLE CANADA ACCIDENT REPORT FORM 808 Pacific Street, Vancouver, BC V6Z 1C2 Tel: 1.604.714.2233 / Fax: 1.604.714.2232 / [email protected]

ATHLETE INFORMATION Name:

Address: Date: DD: MM: YY:

Telephone:

Email: Sex: Male Female

Club/Team:

GENERAL ACCIDENT INFORMATION

DISCIPLINE (SELECT ONE)

MOGULS AERIALS HALFPIPE SLOPESTYLE BIG AIR OTHER

Ski Hill/Training Area Name/Location:

Time of Injury: (Be as specific as possible)

Coach On Location:

DESCRIPTION OF ACCIDENT:

INJURY INFORMATION (CHOOSE ALL OPTIONS THAT APPLY IN EACH MENU)

BODY PART INJURED

Head/Face Neck Shoulder/Clavicle Upper Arm Elbow Forearm Wrist

Hand/Fingers Chest/Ribs Upper Back Abdomen Lower Back Buttocks

Hip/Groin Thigh Knee Lower Leg/Achilles Ankle Foot/Toes

Information Not Available Other:

SITE OR LOCATION OF INJURY

Right Left Middle Other:

INJURY TYPE

Fracture/Bone Stress Joint/Ligament Muscle/Tendon Contusion Laceration

Nervous System Concussion Suspected Concussion Information Not Available

Other:

EXPECTED ABSENCE FROM TRAINING/COMPETITION

No Absence 1 to 3 days 4 to 7 days

8 to 28 days More than 28 days Information Not Available

ACCIDENT REPORT FORM 2016-2017 INJURY CIRCUMSTANCES (CHOOSE ALL OPTIONS THAT APPLY IN EACH MENU)

TYPE OF ACTIVITY

On Snow Training Dry Land Training Water Ramp Trampoline Competition

TYPE OF SNOW (ON SNOW ONLY)

Natural Snow Artificial/Man-made snow (from snow gun)

COURSE CONDITIONS (ON SNOW ONLY)

Icy Soft Compact Fresh Powder Exposed Ground

WEATHER CONDITIONS (choose all that apply)

Sunny/Clear Cloudy/Overcast Raining Snowing

Foggy Flat Light Artificial Light

WIND CONDITIONS (choose all that apply)

No Wind Light Wind Moderate Wind Heavy Wind

TREATMENT INFORMATION

Name of attending physician/para-medical personnel: On-Site Treatment:

IF ATHLETE WAS HOSPITALIZED: Name of Hospital:

Name of Doctor: Hospital Address:

Treatment:

INSURANCE INFORMATION

DID THIS MEMBER PURCHASE FREESTYLE CANADA ACCIDENT INSURANCE WITH THEIR LICENCE?

Yes, 2A (In-Country) Yes, 2B (In-And-Out-Of-Country) No Unknown

Did this member incur any medical fees associated with this injury on the day of the accident? (e.g. ambulance fees, hospital fees, other medical service expenses, etc.)

Yes No Unknown at this time

Does this member expect to incur further medical expenses as a result of this injury? (e.g. physiotherapy, surgery, other medical procedures, etc.)

Yes No Unknown at this time

THIS FORM COMPLETED BY Date: D`D: MM: YY:

Name: Signature/Electronic Signature:

Phone:

THIS SECTION ONLY FOR MEMBERS WHO PURCHASED 2A OR 2B ACCIDENT INSURANCE THROUGH FREESTYLE CANADA: 1. ACCIDENTS OUTSIDE OF CANADA (2B): A) Contact Specialty Assist ASAP after the accident to assess medical options; their contact info is below. B) Complete this form within 24 hours of accident. C) Send to FREESTYLE CANADA ASAP. (Info at top of page). 2. ACCIDENTS WITHIN CANADA (2A/2B): A) Complete this form within 30 days of accident. B) Send this completed form to FREESTYLE CANADA (contact info at top of page). CONTACT AIG ASSIST 24-HR Medical Assistance Service: For any and all medical emergency requiring treatment, hospitalization or emergency repatriation, contact: Canada & USA: +1-877-204-2017 Worldwide: +0-715-295-9967 (collect call) Local Claims Office: +1-877-317-8060 (8:45 am-4:45 pm EST)

ACCIDENT REPORT FORM 2016-2017 POLICY # : SRG 9144067 PLEASE COMPLETE THE CLAIM FORMS IF YOU ARE INTENDING TO MAKE A CLAIM

ACCIDENT REPORT FORM 2016-2017