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If your house/alumni corporation and undergraduate chapter is part of a national fraternity insurance program, you are still required to provide the Executive Diretor/Executive Vice President with notification of this claim.

Date of Incident:
National Fraternity Affiliation:
Chapter Name:
Address:
City:
State
Zip
Phone
Your e-mail address:
Chapter President Name:
Email:
Work Phone:
Home Phone:
Cell Phone:
Fax:
Address:
City:
State:
Zip:
Chapter Advisor Name:
Work Phone:
Home Phone:
Cell Phone:
Fax:
E-mail Address:
Address:
City:
State:
Zip:
House Corp President Name:
E-mail address:
Address:
City:
State:
Zip:
Work Phone:
Home Phone:
Cell Phone:
Fax:
Injured Party's Name:
Email:
Work Phone:
Home Phone:
Cell Phone:
Fax:
Address:
City:
State:
Zip:
Nature of Injury:
Taken to the hospital?: Yes: No:
Hospital:
Admitted:
Is the injured party an associate or member? Yes: No:
Description of What Happened:
Witnesses:
Name Phone Address
Name of person completing report
Date Completed
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