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FORMTEXT       SIGNED: TELEPHONE: ( FORMTEXT    )  FORMTEXT    - FORMTEXT      FAX: ( FORMTEXT    )  FORMTEXT    - FORMTEXT      E-MAIL:  FORMTEXT       PLEASE COMPLETE FORM WITHIN 72 HOURS OF AN ACCIDENT AND SEND TO: Your Association Insurance Chairman     August 2009 Rev 2 8(B(D(F(N(P(d(f(h(r(t(v(~(((((((((((Ʒ֧uƷ֧]uL;L hl$Uh'CJOJQJ^JaJ hl$UhdCJOJQJ^JaJ.jJhl$Uhkbb5OJQJU^JaJ3jhl$Uhkbb5OJQJU^JaJmHnHu.j$hl$Uhkbb5OJQJU^JaJhl$Uhkbb5OJQJ^JaJhl$UhdCJOJQJ^Jhl$Uhd>*CJOJQJ^J(jhl$Uhkbb5OJQJU^JaJ(jhl$Uh{|~5OJQJU^JaJ(H)Z)\)`)b)d)x)z)|)))))))))˼oZE-EZ.jh?hf<^5OJQJU^JaJ(jh?h'5OJQJU^JaJ(jh?h{|~5OJQJU^JaJ.jph?hF;5OJQJU^JaJh?hkbb5OJQJ^JaJ(jh?hkbb5OJQJU^JaJh?h'5OJQJ^JaJhl$UhdCJOJQJ^J hl$Uh'CJOJQJ^JaJ hl$UhdCJOJQJ^JaJ#hl$Uhd>*CJOJQJ^JaJ)))))))))))))))ۮƙƉxgXH3(jh?hkbb5OJQJU^JaJh?h'5OJQJ^JaJhl$UhdCJOJQJ^J hl$Uh'CJOJQJ^JaJ hl$UhdCJOJQJ^JaJhl$Uhd>*CJOJQJ^J(jh?h{|~5CJOJQJU^J.j4h?hf<^5CJOJQJU^J(jh?h'5CJOJQJU^Jh?h'5CJOJQJ^J(jh?h'5OJQJU^JaJ))))*** ** *"*(***,*.*B*¨˜kQA,A(jh?h'5CJOJQJU^Jh?h'5CJOJQJ^J3jh?h'5OJQJU^JaJmHnHu.jh?h'5OJQJU^JaJ(jh?h'5OJQJU^JaJh?h'5OJQJ^JaJ3jh?hkbb5OJQJU^JaJmHnHu(jh?hkbb5OJQJU^JaJ.jh?hF;5OJQJU^JaJh?hkbb5OJQJ^JaJB*D*F*N*P*R*^*`*b*d*x*z*|***ӾӮ}hX@h+h(jhl$Uh{|~5OJQJU^JaJ.jhl$UhF;5OJQJU^JaJhl$Uhkbb5OJQJ^JaJ(jhl$Uhkbb5OJQJU^JaJhl$UhdCJOJQJ^J hl$Uh'CJOJQJ^JaJ hl$UhdCJOJQJ^JaJhl$Uhd>*CJOJQJ^J(jh?hT15CJOJQJU^J(jh?h'5CJOJQJU^J.jJh?h'5CJOJQJU^J)R** ++V+Z+\+`+b+f+h+l+n+----gdP  dhgd\2x dh^gd\2x mdh^gd\2x*+T+V+X+\+^+b+d+h+j+n++ -----ŽŹhW,bhW,bCJaJhPhW,bCJaJhKujhKuU%hl$Uhd6CJOJQJ\]^Jhl$Uhd5CJOJQJ^J2&P:p / =!"#$%$ DText2TEnter full Name of Club. BE CONSISTENT WITH THE NAME YOU USE ON ALL FORMS SENT IN !TEnter full Name of Club. BE CONSISTENT WITH THE NAME YOU USE ON ALL FORMS SENT IN !,DText3.Enter date of accident. Format as "mm/dd/yy"..Enter date of accident. Format as "mm/dd/yy".vDText26vDText27,DText4.Name of the Club Officer filling out the form..Name of the Club Officer filling out the form.\DText5:Telephone number of the Club Officer filling out the form.:Telephone number of the Club Officer filling out the form.tDText6tDText7DText8%Facility name, room, city, and state.%Facility name, room, city, and state.PDText97Full name of the injured person. DO NOT USE NICKNAMES.7Full name of the injured person. 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