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Horse Council British Columbia
Accident Report Form
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YOUR NAME (OR CLUB NAME): _________________________________________________________
ADDRESS:___________________________________________________________________________
CITY:______________________ PHONE NUMBER:______________ FAX NUMBER: _______________
INJURED PERSON NAME: ______________________________________________________________
ADDRESS:___________________________________________________________________________
CITY:___________________ PROVINCE:_________________ PHONE NUMBER:_________________
DATE OF ACCIDENT:_______________________ TIME OF ACCIDENT:_______________ (A.M./P.M.)
LOCATION OF ACCIDENT:______________________________________________________________
WEATHER CONDITIONS:_______________________________________________________________
DESCRIBE WHAT HAPPENED: __________________________________________________________
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WAS AN AMBULANCE CALLED:_______ (Yes/No) HOW LONG BEFORE IT ARRIVED:______________
WAS MEDICAL ASSISTANCE PROVIDED BEFORE THE AMBULANCE ARRIVED:__________ (Yes/No)
IF “YES”, DESCRIBE WHAT ASSISTANCE WAS GIVEN AND BY WHOM:________________________
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WAS THE INJURED PERSON A MINOR:_________ (Yes/No)
IF “YES”, WERE PARENTS/GUARDIANS PRESENT AT THE TIME OF THE ACCIDENT:______ (Yes/No)
PARENT/GUARDIAN NAMES:___________________________________________________________
WERE ANY OTHER PEOPLE PRESENT WHO COULD DESCRIBE WHAT HAPPENED:______ (Yes/No)
IF “YES”, PROVIDE THE FOLLOWING FOR EACH:
NAME ADDRESS PHONE NUMBERS
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IF THE ACCIDENT WAS HORSE RELATED PROVIDE THE FOLLOWING INFORMATION
HORSE NAME:______________________________________________HORSE AGE:______________
NAME OF HORSES OWNER: ___________________________________________________________
ADDRESS: __________________________________________________________________________
CITY:________________________ PROVINCE:________________PHONE
NUMBER:_______________
USE OF HORSE(SCHOOL, PRIVATELY OWNED ETC.):_______________________________________
USUAL TEMPERAMENT OF HORSE:______________________________________________________
DESCRIBE PHYSICAL PROBLEMS OF HORSE THAT MAY HAVE BEEN A CONTRIBUTING FACTOR:
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INDICATE THE HORSE’S EXPERIENCE IN THIS ACTIVITY:____________________________________
HAD THE INJURED PERSON RIDDEN THIS HORSE BEFORE:__________ (Yes/No)
IF “YES”, HOW OFTEN:_________ DID INJURED PERSON SIGN A RELEASE FORM:_______ (Yes/No)
(IF “YES”, ATTACH A COPY OF THE SIGNED FORM)
LIST ANY OTHER DETAILS THAT ARE PERTINENT TO THE ACCIDENT: _______________________
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YOUR SIGNATURE:________________________ DATE:_____________________
PLEASE CONTACT CAPRI INSURANCE AS SOON AS POSSIBLE (1-800-670-1877)
AND FORWARD A COPY OF THIS INFORMATION TO CAPRI INSURANCE (FAX# 250-860-1213) |
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