Insurance Claim
Your Information
Your SHP Email
*
example@shpbeds.org
Your Full Name
*
First Name
Last Name
Your Phone Number
*
Please enter a valid phone number.
Your Chapter
*
What kind of incident are you reporting?
*
Injury
Vehicle Incident
Theft
Fire
Other
Incident Information
When did this incident occur?
*
-
Month
-
Day
Year
Date
FormattedDate
-
Year
-
Month
Day
Date
Did this incident occur on property owned/leased by your Chapter?
*
Yes
No
Do you have any photos related to the incident?
*
Yes
No
Please upload up to five photos from the incident
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Do you have an exact address for where this incident occurred?
*
Yes
No
Incident Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Incident State
*
Please Select
AL
AK
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Please describe where this incident occurred
*
Were there any witnesses to this incident?
*
Yes
No
Witness #1 Name
*
First Name
Last Name
Witness #1 Phone Number
*
Please enter a valid phone number.
Witness #1 Email
*
example@example.com
Witness #2 Name - Optional
First Name
Last Name
Witness #2 Phone Number - Optional
Please enter a valid phone number.
Witness #2 Email - Optional
example@example.com
Please describe what happened
*
Injury Section
Name of the injured party
*
First Name
Last Name
Their Date of Birth - Optional
-
Year
-
Month
Day
Date
Did they sign a volunteer waiver?
*
Yes
No
Phone Number of Injured Party
*
Please enter a valid phone number.
Description of injury
*
Were they transported by an ambulance?
*
Yes
No
Hospital Name
*
Hospital Phone Number
Please enter a valid phone number.
Were the police or fire department involved?
*
Yes
No
Do you have a copy of either report?
*
Yes
No
Please upload the copy of the police and/or fire department report
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Was anyone inside the vehicle or building?
*
Yes
No
How many people were in the vehicle or building?
*
Please Select
1
2
3
4
5
6
Occupant #1 Name
*
First Name
Last Name
Occupant #1 Phone Number
*
Please enter a valid phone number.
Occupant #1 Email
*
example@example.com
Occupant #2 Name
*
First Name
Last Name
Occupant #2 Phone Number
*
Please enter a valid phone number.
Occupant #2 Email
*
example@example.com
Occupant #3 Name
*
First Name
Last Name
Occupant #3 Phone Number
*
Please enter a valid phone number.
Occupant #3 Email
*
example@example.com
Occupant #4 Name
*
First Name
Last Name
Occupant #4 Phone Number
*
Please enter a valid phone number.
Occupant #4 Email
*
example@example.com
Occupant #5 Name
*
First Name
Last Name
Occupant #5 Phone Number
*
Please enter a valid phone number.
Occupant #5 Email
*
example@example.com
Occupant #6 Name
*
First Name
Last Name
Occupant #6 Phone Number
*
Please enter a valid phone number.
Occupant #6 Email
*
example@example.com
Theft
Please describe what was stolen
*
System Information
BHID
Submit
Should be Empty: