HOCKEY CANADA INJURY REPORT
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
City / Town: Province: Postal Code: Phone: ( Parent / Guardian:
Sex:M F )
Birthdate: ——/——/—— Mo. Day Yr.
Initiation Novice Atom Peewee Bantam Midget Juvenile Junior
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 EyeAreaThroat Dental
Back Lower Neck Upper
Trunk Abdomen Ribs Chest
NATURE OF CONDITION
Sprain Strain Contusion Dislocation Separation Internal Organ Injury
Arm:Left Collarbone Right Elbow Shoulder Hand/Finger
Upper arm Forearm/Wrist
Leg:Left Knee RightToe
Shin Thigh Other Foot
On-Site Care Only Refused Care
Sent to Hospital by: Ambulance Car
Name of arena / location:
Exhibition/Regular Season Playoffs/Tournament
Other Warm-up Period #1
Period #2 Period #3
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
Was the injured player in the correct league and level for their age group?
Was this a sanctioned Hockey Canada activity? Yes No
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
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
(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.
(Parent/Guardian if under 18 years of age) Date:
(To be completed by a Team Official) Association:
Team Official (Print):
Team Official Position: Signature:
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:
HOCKEY CANADA INJURY REPORT
Name of Hospital / Clinic: Nature of Injury:
Give the details of injury (degree): Prognosis for recovery:
Tel: ( )
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:
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.
Last name Given name
City / Town Province Postal Code
I HEREBY ASSIGN MY BENEFITS PAYABLE FROM THIS CLAIM DIRECTLY TO THE NAMED DENTIST AND AUTHORIZE PAYMENT DIRECTLY TO HIM / HER
SIGNATURE OF SUBSCRIBER
FOR DENTIST USE ONLY - FOR ADDITIONAL INFORMATION, DIAGNOSIS, PROCEDURES OR SPECIAL CONSIDERATION.
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.
INITIAL TOOTH CODE
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