Athletic Program Insurance Claim
Athletic Program Insurance Claim
Claimant Information
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Name: [Your Name]
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Address: 1234 Elm Street, Springfield, IL 62701
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Phone Number: (555) 123-4567
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Email: [Your Email]
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Date of Birth: January 15, 2025
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Policy Number: AP123456789
Incident Information
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Date of Incident: July 25, 2051
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Time of Incident: 3:00 PM
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Location of Incident: Springfield High School Football Field
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Type of Athletic Program: High School Football Training Camp
Description of Incident
On July 25, 2051, I sustained an injury at the Springfield High School Football Field when another player collided with me during a routine training drill, causing me to fall awkwardly on my left leg and experience severe pain, preventing me from continuing the session.
Injury Details
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Type of Injury: Fractured Left Tibia
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Medical Treatment Received: On-site first aid was administered immediately after the incident. I was then transported to Springfield General Hospital where I underwent X-rays and was diagnosed with a fractured left tibia. I was admitted to the hospital for further treatment and observation.
Medical Provider Information
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Hospital/Clinic Name: Springfield General Hospital
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Doctor’s Name: Dr. Emily Smith
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Doctor’s Contact Number: (555) 987-6543
Additional Information
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Was a Police Report Filed? No
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Was an Incident Report Filed with the Athletic Program? Yes
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If Yes, Provide Report Number: SPR-FB-2051-0725
Insurance Information
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Insurance Company Name: Athletic Program Insurance Co.
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Policy Number: AP123456789
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Claim Number (if already assigned): CLM2051-0725
Signature
By signing below, I certify that the above information is true and accurate to the best of my knowledge.
[Your Name]
