NFHS
Accident Proof of Loss/Claim Form

Note: After filling out this form, a pdf document will be generated with your information. Please print it and mail to Bollinger.

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Section I - To be Completed by Claimant

* First Name:
* Last Name:
* Address:
* City:
* State:
* Zip Code :
* Telephone:
* Birth Date:	MM/DD/YYYY
* Gender:	MaleFemale
* Level of Play	YouthHigh SchoolCollege
* Type of Sport:
* Accident Date:	MM/DD/YYYY
* Accident Time	(ie. 8 PM)
* Body Part Injured:
* Accident Occurred During:	-- Choose One -- Game Practice Tournament Camp/Clinic Other
* Describe how and where the accident occured:
* Name of Field/Facility where accident occurred:

Please note: A $500 deductible applies. The benefit period is 52 weeks.