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Injury and Insurance

FOR ALL ACCIDENTS / INJURIES

Please complete the ONLINE form below to report the injury.

To make a claim for insurance,

Outdoor – FFA Gow Gates Sport Website
5 Aside at the Frat – Indoor Sports NSW

FSC Injury Report

This form is for reporting an injury from football.

Step 1 of 3

33%

Introduction
This form is to notify Football South Coast of an injury which has occurred at a Football Event.
Reporter's Details
Your Name*
First Last
This is the name of the person submitting this form
Email address*

This is the email address for the person submitting this form
Club Associated with*
If you are not associated with a club put NA
Reporter's Age*
Please choose one of the options
I wish to report an accident/injury which has occurred to*
- Myself
- Another Person
My role at the football event was as a*
- Player
- Parent
- Team Official - (Coach / Manager)
- Spectator
- Club Official
- Match Official (Referee or Assistant Referee)
- FSC Offical
- Other

Injury Details
Name of person who had the Injury*
First Last
Date when the Injury Occurred*
Date Format: DD slash MM slash YYYY
The injury occurred during*
Age Group of Match*
Home Team*
Away Team*
What was the event?*
Venue*
When did the accident or injury occur?*
Approximate time e.g. 1:30pm or 1st half of match or 2nd half of match
Where did the accident/ injury occur?*
Was it on the field, sideline, canteen area, seating, ...
How did the accident / injury occur?*
What were the injuries / suspected injuries?*
What treatment for injury / injures (if any) was provided and by whom?
Was an ambulance called?*
Any Additional Information?

Note
This is not a claim form - only a notification to FSC. To commence an insurance claim, you must use the ONLINE - Gow Gates - Personal Injury Claim Form.

Contact details

0242856929
Suite 1, Ground Floor,
45 Chapman Street,
Fairy Meadow NSW 2519
[email protected]

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