Injury Report Form & Return to Play

See reverse for mailing address

Forms must be filled out in full or form will be returned. This form must be completed for each case where an injury is sustained by a player, spectator or any other person at a sanctioned hockey activity

CLAIMS MUST BE PRESENTED WITHIN 90 DAYS OF THE INJURY DATE. DATE OF INJURY: ——/——/—— Mo. Day Yr.

INJURED PARTICIPANT: 􏰀Player 􏰀Team Official 􏰀Game Official 􏰀Spectator

Name:
Address:
City / Town: Province: Postal Code: Phone: ( Parent / Guardian:

Sex:􏰀M 􏰀F )

Birthdate: ——/——/—— Mo. Day Yr.

DIVISION

􏰀 Initiation 􏰀 Novice 􏰀 Atom 􏰀 Peewee 􏰀Bantam 􏰀Midget 􏰀Juvenile 􏰀Junior

CATEGORY

􏰀AAA 􏰀A 􏰀BB 􏰀CC 􏰀DD 􏰀House 􏰀Minor Junior 􏰀Adult Rec. 􏰀AA 􏰀B 􏰀C 􏰀D 􏰀E 􏰀Major Junior 􏰀Senior 􏰀Other

BODY PART INJURED

Head 􏰀 Face 􏰀 Skull 􏰀EyeArea􏰀Throat 􏰀Dental

Back 􏰀 Lower 􏰀Neck 􏰀Upper

Trunk 􏰀Abdomen 􏰀Ribs 􏰀Chest

NATURE OF CONDITION

􏰀Concussion􏰀Laceration 􏰀Fracture
􏰀 Sprain 􏰀 Strain 􏰀 Contusion 􏰀Dislocation 􏰀Separation 􏰀Internal Organ Injury

Arm:􏰀Left 􏰀Collarbone 􏰀Right 􏰀Elbow 􏰀Shoulder 􏰀Hand/Finger

􏰀Upper arm 􏰀Forearm/Wrist

Leg:􏰀Left 􏰀Knee 􏰀Right􏰀Toe

􏰀 Shin 􏰀 Thigh 􏰀 Other 􏰀 Foot

Pelvis

􏰀 Hip 􏰀 Groin

ON-SITE CARE

􏰀On-Site Care Only 􏰀Refused Care

􏰀 Sent to Hospital by: 􏰀 Ambulance 􏰀 Car

INJURY CONDITIONS

Name of arena / location:

􏰀Exhibition/Regular Season 􏰀Playoffs/Tournament
􏰀 Practice
􏰀Try-outs

􏰀Other 􏰀Warm-up 􏰀Period #1

􏰀Period #2 􏰀Period #3
􏰀 Overtime:
􏰀Dry Land Training 􏰀Gradual Onset 􏰀Other Sport 􏰀Other:

CAUSE OF INJURY

􏰀Hit by Puck
􏰀Collision with Boards 􏰀Non-Contact Injury 􏰀Hit by Stick
􏰀Collision on Open Ice 􏰀Collision with Opponent 􏰀Fall on Ice
􏰀Checked from Behind 􏰀Collision with Net
􏰀 Fight
􏰀 Blindsiding

Was the injured player in the correct league and level for their age group?
􏰀Yes 􏰀No

Was this a sanctioned Hockey Canada activity? 􏰀Yes 􏰀No

LOCATION

􏰀Defensive Zone 􏰀Offensive Zone 􏰀Neutral Zone 􏰀 Behind the Net 􏰀 3 ft. from Boards 􏰀 Spectator Area 􏰀Parking Lot 􏰀Dressing Room 􏰀Bench 􏰀Other:

WEARING WHEN INJURED

􏰀Full Face Mask 􏰀Intra-Oral Mouth Guard 􏰀Half Face Shield/Visor 􏰀Throat Protector 􏰀Helmet/No Face Shield 􏰀No Helmet/No Face Shield 􏰀Short Gloves
􏰀Long Gloves

ADDITIONAL

INFORMATION

Has the player sustained this injury before? 􏰀Yes 􏰀No

If “Yes” how long ago
Was a penalty called as a result of the

incident? 􏰀Yes 􏰀No

Estimated absence from hockey?
􏰀1 week 􏰀1-3 weeks 􏰀3+ weeks

DESCRIBE HOW

ACCIDENT HAPPENED

(Attach page if necessary)

I hereby authorize any Health Care Facility, Physician, Dentist or other person who has attended or examined me/my child, to furnish Hockey Canada any and all information with respect to any illness or injury, medical history, consultation, prescriptions or treatment and copies of all dental, hospital, and medical records. A photo static/electronic copy of this authorization shall be considered as effective and valid as the original.

Signed:
(Parent/Guardian if under 18 years of age) Date:

TEAM INFORMATION

(To be completed by a Team Official) Association:
Team Name:
Team Official (Print):

Team Official Position: Signature:
Date:

HEALTH INSURANCE INFORMATION

THIS MUST BE FILLED OUT IN FULL OR FORM PROCESSING WILL BE DELAYED

Occupation: 􏰀Employed Full-time 􏰀Employed Part-time 􏰀Unemployed 􏰀Full-Time Student

Employer (If minor, list parent’s employer):
1. Do you have provincial health coverage? 􏰀Yes 􏰀No Province:

2. Do you have other insurance? 􏰀Yes 􏰀No
(IF “YES”, PLEASE SUBMIT CLAIM TO YOUR PRIMARY HEALTH INSURER.)

3. Has a claim been submitted? 􏰀Yes 􏰀No
(IF “YES”, PLEASE FORWARD PRIMARY INSURER EXPLANATIONS OF BENEFITS.)

Make Claim Payable To: 􏰀Injured Person 􏰀Parent 􏰀Team 􏰀Other:

Branch APPROVAL

PHYSICIAN’S STATEMENT

Physician:
Name of Hospital / Clinic: Nature of Injury:

Give the details of injury (degree): Prognosis for recovery:

Address:

Tel: ( )

Address:

Date of First Attendance:
Claimant will be totally disabled: From: To:

Is the injury permanent and irrecoverable? 􏰀No 􏰀Yes

Did any disease or previous injury contribute to the current injury? 􏰀No 􏰀Yes (describe): Was the claimant hospitalized? 􏰀 No 􏰀 Yes (give hospital name, address and date admitted): Names and addresses of other physicians or surgeons, if any, who attended claimant:

I certify that the above information is correct and to the best of my knowledge, Signed: Date:

DENTIST STATEMENT

Limits of coverage: $1,250 per tooth, $2,500 per accident Treatment must be completed within 52 weeks of accident

UNIQUE NO. SPEC. PATIENT’S OFFICIAL ACCOUNT NO.

Dentist

PHONE NO

I HEREBY ASSIGN MY BENEFITS PAYABLE FROM THIS CLAIM DIRECTLY TO THE NAMED DENTIST AND AUTHORIZE PAYMENT DIRECTLY TO HIM / HER

SIGNATURE OF SUBSCRIBER

I UNDERSTAND THAT THE FEES LISTED IN THIS CLAIM MAY NOT BE COVERED BY OR MAY EXCEED MY PLAN BENEFITS. I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE TO MY DENTIST FOR THE ENTIRE TREATMENT.
I ACKNOWLEGDE THAT THE TOTAL FEE OF $ IS ACCURATE AND HAS BEEN CHARGED TO ME FOR THE SERVICES RENDERED.

I AUTHORIZE RELEASE OF THE INFORMATION CONTAINED IN THIS CLAIM FORM TO MY INSURING COMPANY/PLAN ADMINISTRATOR.

SIGNATURE OF (PATIENT/GUARDIAN) OFFICE VERIFICATION

DATE OF SERVICE DAY / MO. / YR.

PROCEDURE

INITIAL TOOTH CODE

TOOTH SURFACE

DENTIST’S FEE

LAB CHARGE

TOTAL CHARGE

THIS IS AN ACCURATE STATEMENT OF SERVICES PERFORMED AND THE TOTAL FEE DUE AND PAYABLE & OE. NOTE: All benefits subject to insurer payor status, provisions of the policy, Hockey Canada sanctioned events.

TOTAL FEE SUBMITTED

Mail completed form to: BC HOCKEY
6671 Oldfield Road

Saanichton, BC V8M 2A1

Tel: (250) 652-2978 Fax: (250) 652-4536 www.bchockey.net