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Notice of Injury

Please fill out the following information. Someone may contact you if they need further information or clarification.

You will also be asked to sign a copy of the form for our records.

Your name *

Last name

Email address *

Time and Place of Injury

Date of Injury *

Time: *

Time: *

AM

PM

Where did it occur? *

Person Injured

Name *

(Full name)

Age *

Address *

Telephone Number *

Is the injured person a minor? *

Yes

No

Injuries sustained: *

Where was injured taken? *

(Hospital/doctor)

Relationship to organization: *

Member

Visitor

Volunteer

Employee

Student/Camper

Tenant/Resident

Other

Did the injury occur on the insured's premises? *

Yes

No

Who was responsible for supervision at the time of injury? *

Does the injured party have personal medical insurance? *

Yes

No

Full Description of Injury

Describe the injury *

Witnesses

1 - Name

1 - Address

1 - Phone

2 -Name

2 - Address

2 - Phone

Date of Report *

(today's date)

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Georgetown Bible Church
gbc07@gtbible.org
616-669-5690

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