Equestrian Injury Compensation Claim Form
Submit details about an equestrian injury incident, the injuries sustained, and any supporting evidence so a compensation claim can be reviewed.
Claimant Information
Claimant Full Name
*
First Name
Middle Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Preferred Contact Method
Phone
Email
Text Message
Incident Details
Incident Date
*
-
Month
-
Day
Year
Date
Incident Time
Hour Minutes
AM
PM
AM/PM Option
Location of Incident
*
Incident Type
*
Fall from horse
Kicked by horse
Thrown during riding
Collision
Equipment failure
Other equestrian incident
Injury and Medical Information
Describe the injury
*
Body part(s) injured
Head
Neck
Back
Arm/Hand
Leg/Foot
Internal injury
Other
Was medical treatment sought?
*
Yes
No
Current treatment or status
Horse, Site, and Witness Information
Horse name or identifier
Yard, stable, organizer, or responsible party
Witness name(s) and contact detail(s)
Brief description of how the incident occurred
*
Evidence and Claim Summary
Supporting Evidence Uploads
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Compensation Amount Requested (USD)
Claim Summary / Additional Details
*
Submit Claim
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