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<br />Including ALLIANCE OF NONPROFITS FOR INSURANCE (ANI) & <br />NONPROFITS INSURANCE ALLIANCE OF CALIFORNIA (NIAC) <br />www.insurancefornonprofits.org <br /> <br />Rev. 10/2014 Page 1 of 3 <br /> <br />Incident Report Form <br /> <br /> <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 /> <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 /> <br /> <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. <br />( ) <br />Business Fax # <br />( ) <br />E-mail Address <br />Incident Information <br />Date of Incident <br /> <br />Day of Week (circle one) <br />Mon Tue Wed Thurs Fri Sat Sun <br />Time of Incident <br /> AM / PM <br />Did the incident occur on organization’s premises? <br /> Yes No <br />Location of Incident (if 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 /> <br />Witness Information <br />Name and Address Daytime Phone Email Address DOB <br />1. <br /> <br />2. <br /> <br /> <br />DocuSign Envelope ID: 81A61471-345A-47F9-8A2D-36F7929A6637