Incident/Injury Form

Player's Name(*)

Please type the Player's Name

Players ID number(*)

Please type the Players ID number

Team name(*)

Please type the Team name

Ground(*)

Please type the Ground

Date and time of incident(*)

Please Enter the Date and time of incident

Briefly describe the incident andor any injuries(*)

Please describe the incident

If medical assistance was required, what was it? (e.g. icepack)

Was medical assistance required

Who gave the medical assistance (if any)?

Please type who gave the medical assistance

Was an ambulance called?(*)

YesNo

Was an ambulance called?

Is an insurance form required?(*)

YesNo

Is an insurance form required?

Witness 1 name and contact details(*)

Witness 1 name and contact details

Witness 2 name and contact details(*)

Witness 2 name and contact details

Your name and contact details(*)

Your name and contact details

Your Email Address(*)

Invalid Input

FOOTBALL NSW INSURANCE WEBSITE

Football NSW Insurance Website
As a registered player of GlenhavenFC you are covered under the Football NSW Insurance Package.

In addition to submitting your Incident/Injury Report to us, you are also required to submit a claim directly with FNSW. Please visit the links below which will assist in your online claim.