Back to Front Page... -- - Horse Council British Columbia Accident Report Form   YOUR NAME (OR CLUB NAME): _________________________________________________________ ADDRESS:___________________________________________________________________________ CITY:______________________ PHONE NUMBER:______________ FAX NUMBER: _______________ INJURED PERSON NAME: ______________________________________________________________ ADDRESS:___________________________________________________________________________ CITY:___________________ PROVINCE:_________________ PHONE NUMBER:_________________ DATE OF ACCIDENT:_______________________ TIME OF ACCIDENT:_______________ (A.M./P.M.) LOCATION OF ACCIDENT:______________________________________________________________ WEATHER CONDITIONS:_______________________________________________________________ DESCRIBE WHAT HAPPENED: __________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ WAS AN AMBULANCE CALLED:_______ (Yes/No) HOW LONG BEFORE IT ARRIVED:______________ WAS MEDICAL ASSISTANCE PROVIDED BEFORE THE AMBULANCE ARRIVED:__________ (Yes/No) IF “YES”, DESCRIBE WHAT ASSISTANCE WAS GIVEN AND BY WHOM:________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ WAS THE INJURED PERSON A MINOR:_________ (Yes/No) IF “YES”, WERE PARENTS/GUARDIANS PRESENT AT THE TIME OF THE ACCIDENT:______ (Yes/No) PARENT/GUARDIAN NAMES:___________________________________________________________ WERE ANY OTHER PEOPLE PRESENT WHO COULD DESCRIBE WHAT HAPPENED:______ (Yes/No) IF “YES”, PROVIDE THE FOLLOWING FOR EACH: NAME ADDRESS PHONE NUMBERS ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ IF THE ACCIDENT WAS HORSE RELATED PROVIDE THE FOLLOWING INFORMATION HORSE NAME:______________________________________________HORSE AGE:______________ NAME OF HORSES OWNER: ___________________________________________________________ ADDRESS: __________________________________________________________________________ CITY:________________________ PROVINCE:________________PHONE NUMBER:_______________ USE OF HORSE(SCHOOL, PRIVATELY OWNED ETC.):_______________________________________ USUAL TEMPERAMENT OF HORSE:______________________________________________________ DESCRIBE PHYSICAL PROBLEMS OF HORSE THAT MAY HAVE BEEN A CONTRIBUTING FACTOR: ____________________________________________________________________________________ ____________________________________________________________________________________ INDICATE THE HORSE’S EXPERIENCE IN THIS ACTIVITY:____________________________________ HAD THE INJURED PERSON RIDDEN THIS HORSE BEFORE:__________ (Yes/No) IF “YES”, HOW OFTEN:_________ DID INJURED PERSON SIGN A RELEASE FORM:_______ (Yes/No) (IF “YES”, ATTACH A COPY OF THE SIGNED FORM) LIST ANY OTHER DETAILS THAT ARE PERTINENT TO THE ACCIDENT: _______________________ ____________________________________________________________________________________ ____________________________________________________________________________________ YOUR SIGNATURE:________________________ DATE:_____________________ PLEASE CONTACT CAPRI INSURANCE AS SOON AS POSSIBLE (1-800-670-1877) AND FORWARD A COPY OF THIS INFORMATION TO CAPRI INSURANCE (FAX# 250-860-1213)

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