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DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B <br /> Claimant Information <br /> 1.Name of Injured Party DOB ❑ Employee ❑ Client ❑ Volunteer ❑ Visitor <br /> ❑ Other- <br /> Address-Street City State Zip <br /> Home Phone# Business Phone# Email Address <br /> ( ) ( ) <br /> Description of Injury (nature and extent of;please be specific): <br /> Transported by Ambulance Name and Phone#of Hospital or Doctor,if applicable <br /> ❑ Yes ❑ No <br /> Observations of Nonprofit <br /> Claimant's Attire/Description of Clothing(i.e.,shorts,t-shirt) Type of Shoes Was Claimant carrying anything?(if yes,what) <br /> ❑ No ❑ Yes- <br /> Describe claimant's demeanor when making the report (i.e.,agitated,in obvious or no obvious pain,able to move around while describing what happened,etc.) <br /> (use the back of the form or attach an additional sheet of paper if needed) <br /> Claimant Information <br /> 2.Name of Injured Party DOB ❑ Employee ❑ Client ❑ Volunteer ❑ Visitor <br /> ❑ Other- <br /> Address-Street City State Zip <br /> Home Phone# Business Phone# Email Address <br /> ( ) ( ) <br /> Description of Injury (nature and extent of;please be specific): <br /> Transported by Ambulance Name and Phone#of Hospital or Doctor,if applicable <br /> ❑ Yes ❑ No <br /> Observations of Nonprofit <br /> Claimant's Attire/Description of Clothing(i.e.,shorts,t-shirt) Type of Shoes Was Claimant carrying anything?(if yes,what) <br /> ❑ No ❑ Yes- <br /> Describe claimant's demeanor when making the report (i.e.,agitated,in obvious or no obvious pain,able to move around while describing what happened,etc.) <br /> (use the back of the form or attach an additional sheet of paper if needed) <br /> PRINT NAME OF INDIVIDUAL COMPLETING THE FORM SIGNATURE DATE <br /> Rev.10/2014 Page 2 of 3 <br />