Application for injury benefits by a registered participant.
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| (a) Full name: | (a) |
| (b) Address: | (b) |
| (c) Phone no: | (c) |
| (d) Date and year of birth: | (d) |
| (e) Marital status: | (e) |
| (f) Number and ages of dependent children, if any: | (f) |
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| | (a) |
| (Attach a statement by a witness as to how the injury occurred—see clause 5 (a) (iii)) | (b) |
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| (Attach the original or a photocopy of each medical certificate or report obtained with respect to the injury—see clause 5 (a) (i)) | |
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| (a) full name and office held by the official of the sporting organisation to whom the injury was first reported: | (a) |
| (b) time and date the injury was first reported: | (b) |
| (Attach a statement by an official confirming applicant was registered as a participant at the time of injury—see clause 5 (a) (ii)) | |
This information is required for statistical purposes only
Accurate and complete particulars must be provided as required by this form and the Sporting Injuries Insurance Rule 1997 or the application may be rejected.
(If the spaces on the form are insufficient, attach additional pages of particulars.)
All particulars provided by me in, or in any attachment to, this application are true.
| | .........................Signature of Applicant |
Date: / /19
Note:
The Sporting Injuries Insurance Act 1978 provides a penalty for a false or misleading statement made in, or in connection with, this application.
Form S1
(Clause 4 (b))
Supplementary Sporting Injuries Scheme
New South Wales
Application for injury benefits by a school child or participant in an authorised activity of the Department of Tourism, Sport and Recreation.
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| (a) Full name: | (a) |
| (b) Address: | (b) |
| (c) Phone no: | (c) |
| (d) Date and year of birth: | (d) |
| (e) Marital status: | (e) |
| (f) Number and ages of dependent children, if any: | (f) |
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| | (a) |
| (Attach a statement as to how the injury occurred signed by at least one witness—see clause 5 (b) (iii) or (c) (iii)) | (b) |
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| (Attach the original or a photocopy of each medical certificate or report obtained with respect to the injury—see clause 5 (b) (i) or (c) (i)) | |
| | |
| (a) full name and office held by the official of the school or Department to whom the injury was first reported: | (a) |
| (b) time and date the injury was first reported: | (b) |
| (Attach a statement by an official confirming applicant was enrolled as a participant at the time of injury—see clause 5 (b) (ii) or (c) (ii)) | |
This information is required for statistical purposes only
Accurate and complete particulars must be provided as required by this form and the Sporting Injuries Insurance Rule 1997 or the application may be rejected.
(If the spaces on the form are insufficient, attach additional pages of particulars.)
All particulars provided by me in, or in any attachment to, this application are true.
| | .........................Signature of Applicant |
Date: / /19
Note:
The Sporting Injuries Insurance Act 1978 provides a penalty for a false or misleading statement made in, or in connection with, this application.
Form 2
(Clause 4 (c))
Sporting Injuries Insurance Scheme
New South Wales
Application for death benefits for a deceased participant.
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| (a) Name of applicant: | (a) |
| (b) Relationship to deceased | (b) |
| (c) Address: | (c) |
| (d) Phone no: | (d) |
| (e) Name of deceased: | (e) |
| (f) Date and year of birth of deceased: | (f) |
| (g) Marital status of deceased: | (g) |
| (h) Number and ages of dependent children, if any: | (h) |
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| | (a) |
| (Attach a statement by a witness as to how the injury occurred—see clause 5 (d) (iv)) | (b) |
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| (Attach the original or a photocopy of the death certificate and of each medical certificate or report obtained with respect to the injury and death—see clause 5 (d) (i) and (ii)) | |
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| (a) full name and office held by the official of the sporting organisation to whom the injury was first reported: | (a) |
| (b) time and date the injury was first reported: | (b) |
| (Attach a statement by an official confirming deceased was registered as a participant at the time of injury—see clause 5 (d) (iii)) | |
This information is required for statistical purposes only
Unless death occurred immediately or shortly following injury, the information referred to above should be provided (if available) by the person making the application for benefits. In any case, the following question should be answered:
What was the total of the funeral expenses?
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Accurate and complete particulars must be provided as required by this form and the Sporting Injuries Insurance Rule 1997 or the application may be rejected.
(If the spaces on the form are insufficient, attach additional pages of particulars.)
All particulars provided by me in, or in any attachment to, this application are true.
| | .........................Signature of Applicant |
Date: / /19
Note:
The Sporting Injuries Insurance Act 1978 provides a penalty for a false or misleading statement made in, or in connection with, this application.
Form S2
(Clause 4 (d))
Supplementary Sporting Injuries Insurance Scheme
New South Wales
Application for death benefits for a deceased person participating in a school activity or an authorised activity of the Department of Tourism, Sport and Recreation.
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| (a) Name of applicant: | (a) |
| (b) Relationship to deceased: | (b) |
| (c) Address: | (c) |
| (d) Phone no: | (d) |
| (e) Name of deceased: | (e) |
| (f) Date and year of birth of deceased: | (f) |
| (g) Marital status of deceased | (g) |
| (h) Number and ages of dependent children, if any: | (h) |
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| | (a) |
| (Attach a statement by a witness as to how the injury occurred signed by at least one witness—see clause 5 (e) (iv) or (f) (iv)) | (b) |
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| (Attach the original or a photocopy of the death certificate and of each medical certificate or report obtained with respect to the injury and death—see clause 5 (e) (i) and (ii) or (f) (i) and (ii)) | |
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| (a) full name and office held by the official of the school or Department to whom the injury was first reported: | (a) |
| (b) time and date the injury was first reported: | (b) |
| (Attach a statement by an official confirming deceased was enrolled as a participant at the time of injury—see clause 5 (e) (iii) or (f) (iii)) | |
This information is required for statistical purposes only
Unless death occurred immediately or shortly following injury, the information referred to above should be provided (if available) by the person making the application for benefits. In any case, the following question should be answered:
What was the total of the funeral expenses?
............................................................
Accurate and complete particulars must be provided as required by this form and the Sporting Injuries Insurance Rule 1997 or the application may be rejected.
(If the spaces on the form are insufficient, attach additional pages of particulars.)
All particulars provided by me in, or in any attachment to, this application are true.
| | .........................Signature of Applicant |
Date: / /19
Note:
The Sporting Injuries Insurance Act 1978 provides a penalty for a false or misleading statement made in, or in connection with, this application.
Form 3
(Clauses 3A and 3B)
Sporting Injuries Insurance Scheme
New South Wales
Notice of serious injury or death
To be completed by an official representative of the prescribed organisation, or the injured person, or the legal personal representative of the deceased person, in all cases of incidents involving serious injury or death that could result in a claim on the Scheme.
Minor injuries such as sprains, abrasions, cuts, bruises and dental injuries need not be notified.
| 1 | Please indicate, by circling (a) or (b), whether this form is for:(a) a serious injury, or(b) a death. |
| 2 | State—(a) Full name of injured or deceased person:(b) Address of injured or deceased person:(c) Date and year of birth of injured or deceased person: |
| 3 | State name of the prescribed organisation with whom the injured or deceased person was a participant at the time of the incident: |
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| 4 | Provide particulars of the time, date and place of the incident and the activity participated in: |
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| 5 | Provide details of the injury received: |
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| 6 | State the name and address of the attending or treating doctor or doctor certifying death: |
| | .................... | .................... |
| | Signature of injured person or legal personal representative of deceased person | Date |
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| | .................... | .................... |
| | Full name, position and signature of official representative of the prescribed organisation notifying the incident | Date |
Note—
This form is to be lodged with the Sporting Injuries Committee as soon as possible after the incident.