ADIRONDACK MOUNTAIN CLUB
814 GOGGINS ROAD
LAKE GEORGE, NY 12845-4117
ACCIDENT REPORT
PERSON
COMPLETING REPORT: _______________________________________________________
ADDRESS:___________________________________________________ PHONE:
______________(H)
CHAPTER: ___________________________________________________PHONE:______________(W)
DATE OF
ACCIDENT: _____________________ TIME: ________________________
LOCATION: ___________________________________________________________
DESCRIPTION
OF ACCIDENT: (PLEASE ATTACH ADDITIONAL PAGES AS NECESSARY)
PERSON CLAIMING
INJURY OR DAMAGE
NAME:
________________________________________ AGE: _______ PHONE: ____________
ADDRESS: ___________________________________________________________________
IF
PROPERTY, DESCRIBE: ________________________________________________________
IF
INJURY, DESCRIBE: ___________________________________________________________
TAKEN TO
HOSPITAL? ____________________________ DOCTOR? ____________________
IF
ACCIDENT OCCURED ON INSURED PREMISES, WHY WAS PERSON ON THE PERMISES?______
WITNESSES:
NAME: ______________________________________ ADDRESS:_______________________
PH: _________
NAME:
______________________________________ ADDRESS:_______________________ PH:
_________
ANY
POLICE INVOLVED?
ADDITIONAL
COMM ENTS, IF ANY
PERSON COMPLETING THIS REPORT: _________________________________________
DATE: _________
(Signature)
Alter completing this form, please mall to
Headquarters as soon as possible. 2/96