EARLY DAY GAS ENGINE & TRACTOR ASSOCIATION, INC
Notice of Insurance Occurrence/Claim Form Page 1 of 2
Insured Important Please Print or type report
Send a completed form to both:
· EDGETA insurance agent, Jennifer Smith, fax 417-581-4045
· EDGETA insurance contact, Dick Tombrink, fax 406-967-6687 dicknsue@nemontel.net
Name of Show: _________________________________________________________________________
Branch Number: ______ Is it an EDGETA Sponsored Event: Yes No (Circle one) If not explain
Date _________ Time _____________AM/PM (Circle)
Address of where accident happened:
City _____________________________State _________ Zip ________ Phone No __________________
Take Pictures if possible. Film type camera best
Description of the accident: _______________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Equipment involved:
Equipment owned by:
Full name________________________________________ EDGETA Member______ Branch No. ____
Address _____________________________ City ___________________ State __________ Zip ________
Home Phone: ___________________Business Phone: __________________Cell Phone: ____________
Make _________________ Model ______________ SN ________________________________
Was the owner the operator: Yes No (circle one) If answer is No:
Operators name ___________________________________EDGETA Member _____ Branch No. ______
Address ______________________________City ___________________State __________ Zip _______
Home Phone: _________________ Business Phone: ____________________ Cell Phone: _____________
Injured party:
Full name ___________________________________________EDGETA Member _______ Branch _____
Address ______________________________City ___________________ State __________ Zip _______
Home Phone: ________________Business Phone _____________________Cell Phone: _____________
Type of injury: Personal Property (circle correct answer) If Personal
Was emergency personnel called: Yes No (circle one) Was 911 called: Yes No (Circle one)
Whom _______________________________________________________________________________
Response time: ______________minutes
Police Report __________________________________________ Report No.______________________
Ambulance Report ______________________________________________________________________
Wrecker Report ________________________________________________________________________
If Property: Make _______________________ Model __________________ SN ___________________
If an automobile: VN# _________________________________________Tag # _____________State ___
Was vehicle: Moving Parked (circle one)
Where can damaged equipment be viewed: ___________________________________________________
Witnesses: Full name, address, and phone number
#1 __________________________________________________________________Branch No _______
#2 __________________________________________________________________Branch No _______
#3 __________________________________________________________________Branch No _______
Attach statements from all of the above. Witness report on Page 2 of 2
Were the EDGE&TA Safety Requirements being followed: Yes No (Circle One)
EDGETA Branch Contact
Report made by: __________________________________Branch Officer Position: __________________
Address: _______________________________City ________________________ State ____ Zip _______
Phone: _______________________________________Cell Phone: _______________________________
Best time to contact: _____________________________________________________________________
Revised: March 22, 2006
Page 2 of 2
EARLY DAY GAS ENGINE & TRACTOR ASSOCIATION, INC
Notice of Insurance Occurrence/Claim Form
OWNER/OPERATOR/WITNESS
STATEMENT
Date _________ Time _____________ Where ____________________
Full name_____________________________________________ EDGETA Member _____Branch _____
Address _________________________________City ____________________ State ______ Zip _______
Home Phone: __________________ Business Phone______________________ Cell Phone: ___________
When can you be contacted: _______________________________________________________________
OWNER OPERATOR WITNESS
(Circle one)
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Signature:
Use additional pages if necessary
Revised: March 22,2006