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DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B <br /> 1 MI NONPROFITS <br /> ElINSURANCE Including ALLIANCE OF NONPROFITS FOR INSURANCE(ANI) & <br /> NONPROFITS INSURANCE ALLIANCE OF CALIFORNIA(NIAC) <br /> LLIANCE GROUP <br /> www.insurancefornonprofits.org <br /> A Head for Insurance,A Heart for Nonprofits. <br /> Incident Report Form <br /> CLAIMS REPORTING PROCEDURE <br /> If you have a question concerning whether to report an incident or claim,call your broker. <br /> NONPROFIT/INSURED - Complete all items to the best of your ability,sign and date page 2,and immediately give it to your supervisor. <br /> Supervisor - Fax this Incident Report Form to your insurance broker immediately. <br /> Important: Retain any equipment or furniture which caused or contributed to an injury until it can be inspected <br /> by an insurance representative. <br /> BROKER- Refer to our website for instructions on claim reporting. <br /> If a claim needs to be reported after business hours or on the weekend,call(866)718-1947. <br /> This number is reserved for true claims emergencies after business hours and weekends. <br /> General Information <br /> Name of Nonprofit Organization ANI/NIAC Policy Number <br /> Name of Contact Title <br /> Nonprofit Address-Street City State Zip <br /> Business Phone# Ext. Business Fax# E-mail Address <br /> Incident Information <br /> Date of Incident Day of Week(circle one) Time of Incident Did the incident occur on organization's premises? <br /> Mon Tue Wed Thurs Fri Sat Sun AM I PM ❑ Yes ❑ No <br /> Location of Incident Of possible,take pictures of the area with a digital or disposable camera) <br /> Description of Incident (A brief factual account of the incident;include who was involved,how the incident occurred and what action is being taken in <br /> response <br /> to the incident.Use the back of the sheet if more space is needed.) <br /> Witness Information <br /> Name and Address Daytime Phone Email Address DOB <br /> 1. <br /> 2. <br /> Rev.10/2014 Page 1 of 3 <br />