Hunter MH37 - Page 35

Documents and Forms
For each question below, please provide answers IF APPLICABLE AND IF KNOWN, otherwise leave blank.
ACCIDENT DETAILS –
YOUR
BOAT-
INJURED PEOPLE RECEIVING OR IN NEED OF TREATMENT BEYOND FIRST AID
5HSRUWRQO\injured people on, struck by, or being towed by \RXUERDW, receiving RULQQHHGRItreatment beyond first aid. 'RQRWUHSRUW
injured people on, struck by, or being towed by DQRWKHUERDWRUQRERDW(e.g., swimmers, people on a dock). ,IPRUHWKDQRQHinjured person
to report, attach
additional copies of this page. ,IQRQH, SKIP INJURED PEOPLE section.
INJURED PERSON
First Name
MI
Last Name
Street
City
State
Zip
Phone
Date of Birth
PPGG\\\\
Age
INJURY DETAILS
Injury caused when person
VHOHFWDOOWKDWDSSO\
Nature of most serious injury
VHOHFWRQH
Struck the HJERDWZDWHU
Scrape/bruise
Dislocation
Was struck by a HJERDWSURSHOOHU
Cut
Internal organ injury
Was exposed to carbon monoxide poisoning
Sprain/strain
Amputation
Received an electric shock
Concussion/brain injury
Burn
Other GHVFULEH
Spinal cord injury
Other GHVFULEH
Person was wearing lifejacket?
Yes
No
Broken/fractured bone
Person received treatment beyond first aid?
Yes
No
Body part of PRVWVHULRXVinjury HJKHDGWUXQNOHJ
Person was admitted to a hospital?
Yes
No
ACCIDENT DETAILS – YOUR BOAT – DEATHS/DISAPPEARANCES
2QO\report deaths/disappearances of people on, struck by, or being towed by \RXUERDW.
If more than one death/disappearance to report, attach additional copies of this page.
,IQRQH, SKIP DEATHS/DISAPPEARANCES section.
PERSON WHO DIED/DISAPPEARED
First Name
MI
Last Name
Street
City
State
Zip
Phone
Date of Birth
PPGG\\\\
Age
DETAILS OF DEATH/DISAPPEARANCE
Injury caused when person VHOHFWDOOWKDWDSSO\
Nature of death/disappearance VHOHFWRQH
Struck the HJERDWZDWHU
Death – by drowning
Was struck by a HJERDW
SURSHOOHU
Death – other likely cause GHVFULEH
Was exposed to carbon monoxide poisoning
Received an electric shock
Disappeared and not yet recovered
Other GHVFULEH
Person was wearing lifejacket?
Yes
No
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