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1029B IncidentReport 1-09 1029B K&K_INCIDENT_REPORT 1-09

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1712 Magnavox Way P.O. Box 2338
Fort Wayne, Indiana 46801
(800) 237-2917 Fax (260) 459-5910
http://www.kandkinsurance.com
K&K
INCIDENT
REPORT
(PLEASE PRINT)
NATURE BODILY INJURY PROPERTY DAMAGE OTHER:
TIME & PLACE DATE: TIME: AM PM
OF INCIDENT EVENT:
SPORT: SANCTIONED BY:
LOCATION:
HAPPENED TO NAME:
AGE: SEX: Male Female PHONE: ( )
ADDRESS:
CITY: STATE: ZIP:
FUNCTION AS: PARTICIPANT VOLUNTEER SPECTATOR BYSTANDER OFFICIAL
OTHER:
APPARENT BODY PART:
INJURY CONDITION: (Laceration, Concussion, Sprain, Fracture, Etc.):
OR DAMAGE ON-SITE CARE ONLY, BY (PHYSICIAN) (EMT) (TRAINER) OTHER:
AMBULANCE, TAKEN TO: CITY:
FATALITY
OCCASION WHAT WAS THE SITUATION AND EXACT LOCATION AT THE TIME OF THE INCIDENT?
INCIDENT DESCRIBE WHAT HAPPENED:
DESCRIPTION
WITNESSES NAME: NAME:
ADDRESS: ADDRESS:
PHONE: PHONE: ( )
INSURED NAME OF INSURED: POLICY#:
CLUB NAME`: CITY/STATE:
COACH/OFFICIAL/ NAME: PHONE: ( )
TEAM OR LEAGUE TITLE: ORGANIZATION:
REPRESENTATIVE SIGNATURE:
DATE:
COMPLETE ALL SECTIONS AND FAX TO (260) 459-5910 OR MAIL IMMEDIATELY TO:
K&K INSURANCE GROUP, INC., P.O. BOX 2338, FORT WAYNE, IN 46801-2338
THIS FORM MUST INCLUDE THE INSURED NAME, POLICY NUMBER, AND SIGNATURE OF THE INSURED/REPRESENTATIVE
BEFORE RETURNING OR PROCESSING MAY BE DELAYED
1029B 1/09
1029B 1/09
Applicable in Arizona
For your protection, Arizona law requires the following statement to appear
on this form. Any person who knowingly presents a false or fraudulent claim
for payment of a loss is subject to criminal and civil penalties.
Applicable in Arkansas, Delaware, District of Columbia, Kentucky,
Louisiana, Maine, Michigan, New Jersey, New Mexico, New York,
North Dakota, Pennsylvania, South Dakota, Tennessee, Texas,
Virginia, Washington and West Virginia
Any person who knowingly and with intent to defraud any insurance compa-
ny or another person, files a statement of claim containing any materially
false information, or conceals for the purpose of misleading, information
concerning any fact, material thereto, commits a fraudulent insurance act,
which is a crime, subject to criminal prosecution and [NY: substantial] civil
penalties. In DC, LA, ME, TN, VA and WA, insurance benefits may also be
denied.
Applicable in California
For your protection, California law requires the following to appear on this
form: Any person who knowingly presents a false or fraudulent claim for
payment of a loss is guilty of a crime and may be subject to fines and con-
finement in state prison.
Applicable in Colorado
It is unlawful to knowingly provide false, incomplete, or misleading facts or
information to an insurance company for the purpose of defrauding or
attempting to defraud the company. Penalties may include imprisonment,
fines, denial of insurance, and civil damages. Any insurance company or
agent of an insurance company who knowingly provides false, incomplete,
or misleading facts or information to a policy holder or claimant for the pur-
pose of defrauding or attempting to defraud the policy holder or claimant
with regard to a settlement or award payable from insurance proceeds shall
be reported to the Colorado Division of Insurance within the Department of
Regulatory Agencies.
Applicable in Florida and Idaho
Any person who knowingly and with the intent to injure, defraud, or deceive
any insurance company files a statement of claim containing any false,
incomplete or misleading information is guilty of a felony.*
* In Florida - Third Degree Felony
Applicable in Hawaii
For your protection, Hawaii law requires you to be informed that presenting
a fraudulent claim for payment of a loss or benefit is a crime punishable by
fines or imprisonment, or both.
Applicable in Indiana
A person who knowingly and with intent to defraud an insurer files a state-
ment of claim containing any false, incomplete, or misleading information
commits a felony.
Applicable in Minnesota
A person who files a claim with intent to defraud or helps commit a fraud
against an insurer is guilty of a crime.
Applicable in Nevada
Pursuant to NRS 686A.291, any person who knowingly and willfully files a
statement of claim that contains any false, incomplete or misleading infor-
mation concerning a material fact is guilty of a felony.
Applicable in New Hampshire
Any person who, with purpose to injure, defraud or deceive any insurance
company, files a statement of claim containing any false, incomplete or mis-
leading information is subject to prosecution and punishment for insurance
fraud, as provided in RSA 638:20.
Applicable in Ohio
Any person who, with intent to defraud or knowing that he/she is facilitating
a fraud against an insurer, submits an application or files a claim containing
a false or deceptive statement is guilty of insurance fraud.
Applicable in Oklahoma
WARNING: Any person who knowingly and with intent to injure, defraud or
deceive any insurer, makes any claim for the proceeds of an insurance poli-
cy containing any false, incomplete or misleading information is guilty of a
felony.
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1029B IncidentReport 1-09 1029B K&K_INCIDENT_REPORT 1-09

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Completed 2 July 2020

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