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7609 W. Jefferson Blvd. Suite 150 Fort Wayne Indiana 46804-4133 Fax 260. 969. 4729 IF INJURY WAS SERIOUS OR A FATALITY IMMEDIATELY NOTIFY AMERICAN SPECIALTY AT 800. Describe how the accident occurred Attach a separate sheet if necessary Site / event where accident occurred BODY PART INJURED SPORT ACCIDENT OCCURRED DURING DURING Training/Practice Competition Traveling to or from SO event Severe cut w/ bleeding Less serious bruise or cut Break/fracture Concussion Paralysis Fatality DISPOSITION...
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