Equine Risk Management
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Equine Related Accident Report Form
YOUR NAME:_______________________________________________________________________ ADDRESS:__________________________________________________________________________ CITY:____________________PROV:________PHONE:_________________FAX:_________________ INJURED PERSON NAME:____________________________________________________________ ADDRESS:__________________________________________________________________________ CITY:______________________________ PROVINCE:______________ PHONE:_______________ DATE OF ACCIDENT:_____________________ TIME OF ACCIDENT:_______________(AM/PM) LOCATION OF ACCIDENT:__________________________________________________________ WEATHER CONDITIONS:___________________________________________________________ DESCRIBE WHAT HAPPENED:______________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ WAS AN AMBULANCE CALLED:________(Yes/No) HOW LONG TO ARRIVE:______________ MEDICAL ASSISTANCE PROVIDED BEFORE AMBULANCE ARRIVED:________(Yes/No) IF "YES", DESCRIBE WHAT ASSISTANCE WAS GIVEN AND BY WHOM: ____________________________________________________________________________ ____________________________________________________________________________ WAS THE INJURED PERSON A MINOR:_________ (Yes/No) IF "YES", PARENTS/GUARDIANS PRESENT AT TIME OF ACCIDENT:_______(Yes/No) PARENT/GUARDIAN NAMES:_________________________________________________ ____________________________________________________________________________ WERE OTHER PEOPLE PRESENT TO DESCRIBE WHAT HAPPENED:_______(Yes/No) IF "YES", PROVIDE THE FOLLOWING FOR EACH:
____________________________________________________________________________ ____________________________________________________________________________ IF THE ACCIDENT WAS HORSE RELATED PROVIDE INFORMATION ON THE HORSE HORSE NAME:________________________________________HORSE AGE:___________ NAME OF HORSE OWNER:___________________________________________________ ADDRESS: _________________________________________________________________ CITY:________________________PROVINCE:______________PHONE:_______________ USE OF HORSE(SCHOOL HORSE, ETC.):________________________________________ USUAL TEMPERAMENT OF HORSE:___________________________________________ PHYSICAL PROBLEMS OF HORSE THAT MAY HAVE CONTRIBUTED TO ACCIDENT: ____________________________________________________________________________ ____________________________________________________________________________ INDICATE HORSE'S EXPERIENCE IN THIS ACTIVITY:____________________________ HAD THE INJURED PERSON RIDDEN THIS HORSE BEFORE:__________ (Yes/No) IF "YES", HOW OFTEN:__________ DID THEY SIGN A RELEASE FORM:_______(Yes/No) IF "YES", ATTACH A COPY OF THE SIGNED FORM LIST ANY OTHER DETAILS THAT ARE PERTINENT TO ACCIDENT: ____________________________________________________________________________ ____________________________________________________________________________ YOUR SIGNATURE:__________________________ DATE:______________________ Contact Intercity Insurance as soon as possible at 1-888-394-3330 or Fax (905)-841-0030
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