PLEASE SCROLL DOWN TO COMPLETE AN INCIDENT REPORT FORM

A Disabled Sports USA dba Move United incident report form must be completed by chapters participating in the Move United insurance program to document any unexpected occurrence (injury, sickness, assault, etc.) regardless of whether or not medical attention was required. All appropriate staff and volunteers should be properly trained on this process and the forms should be available at all activity sites. The incident report form must be submitted via the electronic incident reporting form below or by completing a copy of the form FOUND HERE and emailing it to claimcentral@willistowerswatson.com, with a CC to rsemke@moveunitedsport.org. A sample of a properly detailed/completed incident report form can be found below.

Sample Incident Report – No Injury

Sample Incident Report – Major Injury or Illness

Below are the procedures for ensuring proper incident reporting:

• Complete, in detail, all areas of the report form
• Provide sufficient details to ensure that anyone who did not witness the incident will be able to understand exactly what occurred
  • Keep all narratives to known facts. Do not speculate on how the injury occurred or  injuries that have not been verified by a trained medical professional (i.e. “kayak fell on Timmy” vs. “kayak fell on Timmy because the last person may not have properly secured it” or “Susie complained of pain in her knee” vs. “Susie sprained her knee”)
  • Use personal names when detailing the incident, avoid the use of pronouns (he, she, they, we)
  • When multiple witnesses viewed the incident, each witness shall complete a separate Incident Report Form to help ensure all details are captured
  • When needed, attach additional pages to completely detail the incident
• When available, attach all relevant documentation by treatment providers (i.e. ski patrol, lifeguard, paramedic, EMT, etc.)

The completed incident report form along with the Disabled Sports USA dba Move United Waiver & Release Form and Registration Form must be submitted within 24 hours of the incident.