Evergreen USA | Insurance for the Outdoor Recreation Industry | Forms

Online Claim Report

To be completed by campground staff, not injured or involved person(s).

This form is intended for recording & reporting of all non-employee injuries/incidents, regardless of whether or not the injured person received medical treatment. If the injured person is an employee, a Workers Compensation Reporting form should be completed. (Workers Compensation Employee Reporting Form may be required, in your state, to he provided to the employee within 24 hours of any injury.)

Campground or R.V. Park Information

Name of Campground:
Street:
City:
State:
Zip:
Telephone Number:
Person to Contact:
Email Address:

Specific Information Related to Incident

Date of Incident:
Date Incident Reported:
Time Incident Occurred: AM PM
Specific Location of Incident in Park:

Specific Information on Injured Person or Person Involved

Person's Name:
Age:
Sex: Male Female
Person's Address:
City:
State:
Zip:
If Minor, Name of Parent/Guardian:
Relationship:
Phone Number / Notations:

Description of Incident

Written By:

Medical Response

Check here if no one was injured
Was First Aid Provided at Scene? Yes No
If Yes, By Whom:
Park Staff? Yes No
Was the injured person taken for treatment? Yes No
If No, was treatment recommended by park staff? Yes No
If treated, where?
Transported By:
Describe Injury & Treatment

Witness Information (list both employee and non-employee witnesses)

Name:
Eye Witness Second Hand
Relationship to Person:
Address:
City:
State:
Zip:
Phone # / Notation:

Name:
Eye Witness Second Hand
Relationship to Person:
Address:
City:
State:
Zip:
Phone # / Notation:

Name:
Eye Witness Second Hand
Relationship to Person:
Address:
City:
State:
Zip:
Phone # / Notation:

Notes: (See instruction block regarding evidence protection.)

Notes:
Report completed by:
Title:
Date:
Check here if you want us to return a copy for your file.