Claims Reporting Form — Canadian Camping Association Insurance

GENERAL CAMP INFORMATION
Name of Camp*
Address of Camp*
Street Address City State / Province / Region ZIP / Postal Code
Contact Person at Camp*
First Name Last Name
Email Address of Camp Contact*
Phone*
Fax*
Is this claim a loss of your own property or liability?*
- Loss of my own property
- Liability

LOSS OF PROPERTY
Date of Loss*
Is this Claim for Damage or Loss?*
- Damage
- Loss
- Both
Where did the loss occur?*
Type of Damage*
(i.e., Fire, Windstorm, Theft, Flood)
Type of Property Lost, Damaged or Destroyed*
(i.e., Cabin, Boat)
Briefly describe to the best of your knowledge how such damage occurred.*
INJURIES TO PERSONS
Date of Injury*
Name of Injured Party*
First Name Last Name
Address of Injured Party*
Street Address City State / Province / Region ZIP / Postal Code Country
Type of Injury*
- Bodily Injury
- Abuse
Briefly describe to the best of your knowledge how such injury occurred.*

PROPERTY AND LIABILITY CLAIMS REPORTING FORM