"Student Accident Report Form - Gallagher Bassett Services" - Michigan

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STUDENT ACCIDENT REPORT
SCHOOL ___________________________________ MCC UNIT NO. __________ PHONE: (______)______-_____________
ADDRESS: _________________________________________________ CITY: ___________________ ZIP:_________________
NAME OF INJURED STUDENT: _____________________________DATE OF BIRTH: ________________GRADE: _______
SSN__________________________
PARENT’S NAME: ___________________________________________________
PHONE: (______)______-_____________
PARENT’S ADDRESS: ___________________________________
_________________________
___________________
(NUMBER & STREET)
(CITY)
(ZIP)
DATE OF ACCIDENT: _________________________________ TIME: _____________
AM _______
PM __________
SPECIFIC LOCATION OF ACCIDENT: _______________________________________________________________________
PERSON SUPERVISING: __________________________________________
TITLE: ________________________________
_____________________________________________________________
DESCRIBE HOW ACCIDENT OCCURRED:
_________________________________________________________________________________________________
_____________________________________________________________________________________________
DESCRIBE ACCIDENT LOCATION, SURFACE AND CONDITION: _____________________________________________
__________________________________________________________________________________________________________
DESCRIBE INJURY, EXTENT, AND PART OF BODY: __________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
NAME OF PERSON PROVIDING FIRST AID: _________________________________________________________________
DESCRIBE FIRST AID ADMINISTERED: _____________________________________________________________________
_________________________________________________________________________________________________
WERE PARENTS NOTIFIED? YES ____ NO ____ HOW? _______________________________________________________
BY WHOM? _____________________________________________________ AT WHAT TIME? _______________________
LIST WITNESSES, ADDRESSES, AND PHONE NUMBERS:
______________________________
________________________________
____________________________
______________________________
________________________________
____________________________
______________________________
________________________________
____________________________
PERSON MAKING REPORT: ____________________________________________ PHONE (_____)_____-_______________
TITLE: ____________________________________________________
DATE OF REPORT: _________________________
ALL ACCIDENTS SHOULD BE REPORTED TO THE PRINCIPAL’S OFFICE ON THIS FORM ON THE DAY THEY OCCUR.
STUDENT ACCIDENT SUPPLEMENTAL INSURANCE IS PROVIDED BY A SEPARATE PROGRAM THROUGH MICHIGAN
CATHOLIC CONFERENCE. HOWEVER, TO PROTECT THE DIOCESE FROM POTENTIAL LIABILITY, THIS REPORT MUST BE
COMPLETED FOR ALL INJURIES OTHER THAN MINOR CUTS AND BRUISES.
PLEASE REPORT ALL INJURIES IMMEDIATELY TO GALLAGHER BASSETT SERVICES, INC.:
2601 CAMBRIDGE COURT SUITE 435
AUBURN HILLS MI 48326
(248) 452-6050 FAX (248) 475-0228
RM: 03/12
STUDENT ACCIDENT REPORT
SCHOOL ___________________________________ MCC UNIT NO. __________ PHONE: (______)______-_____________
ADDRESS: _________________________________________________ CITY: ___________________ ZIP:_________________
NAME OF INJURED STUDENT: _____________________________DATE OF BIRTH: ________________GRADE: _______
SSN__________________________
PARENT’S NAME: ___________________________________________________
PHONE: (______)______-_____________
PARENT’S ADDRESS: ___________________________________
_________________________
___________________
(NUMBER & STREET)
(CITY)
(ZIP)
DATE OF ACCIDENT: _________________________________ TIME: _____________
AM _______
PM __________
SPECIFIC LOCATION OF ACCIDENT: _______________________________________________________________________
PERSON SUPERVISING: __________________________________________
TITLE: ________________________________
_____________________________________________________________
DESCRIBE HOW ACCIDENT OCCURRED:
_________________________________________________________________________________________________
_____________________________________________________________________________________________
DESCRIBE ACCIDENT LOCATION, SURFACE AND CONDITION: _____________________________________________
__________________________________________________________________________________________________________
DESCRIBE INJURY, EXTENT, AND PART OF BODY: __________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
NAME OF PERSON PROVIDING FIRST AID: _________________________________________________________________
DESCRIBE FIRST AID ADMINISTERED: _____________________________________________________________________
_________________________________________________________________________________________________
WERE PARENTS NOTIFIED? YES ____ NO ____ HOW? _______________________________________________________
BY WHOM? _____________________________________________________ AT WHAT TIME? _______________________
LIST WITNESSES, ADDRESSES, AND PHONE NUMBERS:
______________________________
________________________________
____________________________
______________________________
________________________________
____________________________
______________________________
________________________________
____________________________
PERSON MAKING REPORT: ____________________________________________ PHONE (_____)_____-_______________
TITLE: ____________________________________________________
DATE OF REPORT: _________________________
ALL ACCIDENTS SHOULD BE REPORTED TO THE PRINCIPAL’S OFFICE ON THIS FORM ON THE DAY THEY OCCUR.
STUDENT ACCIDENT SUPPLEMENTAL INSURANCE IS PROVIDED BY A SEPARATE PROGRAM THROUGH MICHIGAN
CATHOLIC CONFERENCE. HOWEVER, TO PROTECT THE DIOCESE FROM POTENTIAL LIABILITY, THIS REPORT MUST BE
COMPLETED FOR ALL INJURIES OTHER THAN MINOR CUTS AND BRUISES.
PLEASE REPORT ALL INJURIES IMMEDIATELY TO GALLAGHER BASSETT SERVICES, INC.:
2601 CAMBRIDGE COURT SUITE 435
AUBURN HILLS MI 48326
(248) 452-6050 FAX (248) 475-0228
RM: 03/12