ACCIDENT/INCIDENT REPORT FORM
Instructions: Complete fully and submit to:
GSWPA, 30 Isabella Street, Suite 107, Pittsburgh, PA 15212 – ATTN: Accident/Incident Report
This form must be complete immediately upon an accident or incident that requires more than routine
first-aid care. It is also required when there has been an incident that requires special attention. Be very
specific and provide all details. Use additional sheets of paper if necessary. If the person involved in the
accident would like to submit an insurance claim, please have them submit appropriate bills and insurance
statements with the Mutual of Omaha Claim Form to the address listed above, ATTN: Insurance Claim.
Name of person involved in accident/incident
Troop/group
# Phone
Address
Street
City
State
Zip
If more than one person was involved in the accident/incident, please list their name, address, phone
number and troop number on a separate sheet of paper and attach to this report
Name of person making report
Position
Phone
Address
Street
City
Date of occurrence
State
Zip
Exact time of occurrence
Location of occurrence
Parent/guardian name
Phone
Address
Street
City
State
Zip
Give specific details of what happened (Attach additional pages if needed):
What steps were taken and by whom?
Parent/guardian comments/reaction when notified by the adult in charge of the event:
OVER
157