<p> FREESTYLE CANADA ACCIDENT REPORT FORM 808 Pacific Street, Vancouver, BC V6Z 1C2 Tel: 1.604.714.2233 / Fax: 1.604.714.2232 / [email protected]</p><p>ATHLETE INFORMATION Name:</p><p>Address: Date: DD: MM: YY:</p><p>Telephone:</p><p>Email: Sex: Male Female</p><p>Club/Team:</p><p>GENERAL ACCIDENT INFORMATION</p><p>DISCIPLINE (SELECT ONE)</p><p>MOGULS AERIALS HALFPIPE SLOPESTYLE BIG AIR OTHER</p><p>Ski Hill/Training Area Name/Location:</p><p>Time of Injury: (Be as specific as possible)</p><p>Coach On Location:</p><p>DESCRIPTION OF ACCIDENT:</p><p>INJURY INFORMATION (CHOOSE ALL OPTIONS THAT APPLY IN EACH MENU)</p><p>BODY PART INJURED</p><p>Head/Face Neck Shoulder/Clavicle Upper Arm Elbow Forearm Wrist</p><p>Hand/Fingers Chest/Ribs Upper Back Abdomen Lower Back Buttocks</p><p>Hip/Groin Thigh Knee Lower Leg/Achilles Ankle Foot/Toes</p><p>Information Not Available Other: </p><p>SITE OR LOCATION OF INJURY</p><p>Right Left Middle Other:</p><p>INJURY TYPE</p><p>Fracture/Bone Stress Joint/Ligament Muscle/Tendon Contusion Laceration</p><p>Nervous System Concussion Suspected Concussion Information Not Available</p><p>Other:</p><p>EXPECTED ABSENCE FROM TRAINING/COMPETITION</p><p>No Absence 1 to 3 days 4 to 7 days</p><p>8 to 28 days More than 28 days Information Not Available</p><p>ACCIDENT REPORT FORM 2016-2017 INJURY CIRCUMSTANCES (CHOOSE ALL OPTIONS THAT APPLY IN EACH MENU)</p><p>TYPE OF ACTIVITY</p><p>On Snow Training Dry Land Training Water Ramp Trampoline Competition</p><p>TYPE OF SNOW (ON SNOW ONLY)</p><p>Natural Snow Artificial/Man-made snow (from snow gun)</p><p>COURSE CONDITIONS (ON SNOW ONLY)</p><p>Icy Soft Compact Fresh Powder Exposed Ground</p><p>WEATHER CONDITIONS (choose all that apply)</p><p>Sunny/Clear Cloudy/Overcast Raining Snowing</p><p>Foggy Flat Light Artificial Light</p><p>WIND CONDITIONS (choose all that apply)</p><p>No Wind Light Wind Moderate Wind Heavy Wind</p><p>TREATMENT INFORMATION </p><p>Name of attending physician/para-medical personnel: On-Site Treatment:</p><p>IF ATHLETE WAS HOSPITALIZED: Name of Hospital:</p><p>Name of Doctor: Hospital Address:</p><p>Treatment:</p><p>INSURANCE INFORMATION</p><p>DID THIS MEMBER PURCHASE FREESTYLE CANADA ACCIDENT INSURANCE WITH THEIR LICENCE?</p><p>Yes, 2A (In-Country) Yes, 2B (In-And-Out-Of-Country) No Unknown</p><p>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.)</p><p>Yes No Unknown at this time</p><p>Does this member expect to incur further medical expenses as a result of this injury? (e.g. physiotherapy, surgery, other medical procedures, etc.)</p><p>Yes No Unknown at this time</p><p>THIS FORM COMPLETED BY Date: D`D: MM: YY:</p><p>Name: Signature/Electronic Signature:</p><p>Phone:</p><p>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) </p><p>ACCIDENT REPORT FORM 2016-2017 POLICY # : SRG 9144067 PLEASE COMPLETE THE CLAIM FORMS IF YOU ARE INTENDING TO MAKE A CLAIM</p><p>ACCIDENT REPORT FORM 2016-2017</p>