Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 7 (2009/05)
Aviation Injured Schedule
ACORD 7, Aviation Injured Schedule, is used when additional space
is required to list injured parties when reporting an aviation loss.
IDENTIFICATION SECTION Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g.
agency or brokerage).
IDENTIFICATION SECTION Page #
Enter number: The page number applicable to this page.
IDENTIFICATION SECTION of Total Pages
Enter number: The total number of pages applicable to this form (e.g., Page 1 of 4). If
only one page, indicate Page 1 of 1.
IDENTIFICATION SECTION Agency
Enter text: The full name of the producer/agency.
IDENTIFICATION SECTION Named Insured
Enter text: The named insured(s) as it/they will appear on the policy declarations page.
IDENTIFICATION SECTION Policy Number
Enter identifier: The identifier assigned by the insurer to the policy, or submission, being
referenced exactly as it appears on the policy, including prefix and suffix symbols. If
required for self-insurance, the self-insured license or contract number.
IDENTIFICATION SECTION Effective Date
Enter date: The effective date of the policy. The date that the terms and conditions of the
policy commence.
IDENTIFICATION SECTION Carrier
Enter text: The insurer's full legal company name(s) as found in the file copy of the policy.
Use the actual name of the company within the group to which the policy has been issued.
This is not the insurer's group name or trade name.
IDENTIFICATION SECTION NAIC Code
Enter code: The identification code assigned to the insurer by the NAIC.
INJURED
#
Enter number: The producer assigned number for the injured party.
INJURED
Name & Address
Enter text: The name of a person that was injured in the incident or accident.
INJURED
Enter text: The first address line of the injured party.
INJURED
Enter text: The second address line of the injured party.
INJURED
Enter text: The city of the injured party.
INJURED
Enter code: The state or province of the injured party.
INJURED
Enter code: The postal code of the injured party.
INJURED
Home Phone
Enter number: The primary phone number of the injured party. As used here, this is the
home phone number.
INJURED
Business Phone
Enter number: The secondary phone number of the injured party. As used here, this is the
business phone number.
INJURED
Cell Phone
Enter number: The third phone number of the injured party. As used here, this is the cell
phone number.
ACORD 7 (2009/05)
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Section Name
Field Name
Field and/or Section Description
INJURED
Insured Aircraft
Check the box (if applicable): Indicates if the injured party was in the insured's aircraft.
INJURED
Other Aircraft
Check the box (if applicable): Indicates if the injured party was in an aircraft other than the
insured's aircraft at the time of the incident or accident.
INJURED
Other Checkbox
Check the box (if applicable): Indicates if the injured party was in a location other than
those listed.
INJURED
Other Description
Enter text: The location of the injured party at the time of the incident or accident.
INJURED
Age
Enter number: The age, at the time of the incident, of the injured party.
INJURED
Extent of Injury
Enter text: A brief description of the injury sustained by the injured party (e.g. broken left
leg).
INJURED
#
Enter number: The producer assigned number for the injured party.
INJURED
Name & Address
Enter text: The name of a person that was injured in the incident or accident.
INJURED
Enter text: The first address line of the injured party.
INJURED
Enter text: The second address line of the injured party.
INJURED
Enter text: The city of the injured party.
INJURED
Enter code: The state or province of the injured party.
INJURED
Enter code: The postal code of the injured party.
INJURED
Home Phone
Enter number: The primary phone number of the injured party. As used here, this is the
home phone number.
INJURED
Business Phone
Enter number: The secondary phone number of the injured party. As used here, this is the
business phone number.
INJURED
Cell Phone
Enter number: The third phone number of the injured party. As used here, this is the cell
phone number.
INJURED
Insured Aircraft
Check the box (if applicable): Indicates if the injured party was in the insured's aircraft.
INJURED
Other Aircraft
Check the box (if applicable): Indicates if the injured party was in an aircraft other than the
insured's aircraft at the time of the incident or accident.
INJURED
Other Checkbox
Check the box (if applicable): Indicates if the injured party was in a location other than
those listed.
INJURED
Other Description
Enter text: The location of the injured party at the time of the incident or accident.
INJURED
Age
Enter number: The age, at the time of the incident, of the injured party.
INJURED
Extent of Injury
Enter text: A brief description of the injury sustained by the injured party (e.g. broken left
leg).
INJURED
#
Enter number: The producer assigned number for the injured party.
INJURED
Name & Address
Enter text: The name of a person that was injured in the incident or accident.
INJURED
Enter text: The first address line of the injured party.
ACORD 7 (2009/05)
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Section Name
Field Name
Field and/or Section Description
INJURED
Enter text: The second address line of the injured party.
INJURED
Enter text: The city of the injured party.
INJURED
Enter code: The state or province of the injured party.
INJURED
Enter code: The postal code of the injured party.
INJURED
Home Phone
Enter number: The primary phone number of the injured party. As used here, this is the
home phone number.
INJURED
Business Phone
Enter number: The secondary phone number of the injured party. As used here, this is the
business phone number.
INJURED
Cell Phone
Enter number: The third phone number of the injured party. As used here, this is the cell
phone number.
INJURED
Insured Aircraft
Check the box (if applicable): Indicates if the injured party was in the insured's aircraft.
INJURED
Other Aircraft
Check the box (if applicable): Indicates if the injured party was in an aircraft other than the
insured's aircraft at the time of the incident or accident.
INJURED
Other Checkbox
Check the box (if applicable): Indicates if the injured party was in a location other than
those listed.
INJURED
Other Description
Enter text: The location of the injured party at the time of the incident or accident.
INJURED
Age
Enter number: The age, at the time of the incident, of the injured party.
INJURED
Extent of Injury
Enter text: A brief description of the injury sustained by the injured party (e.g. broken left
leg).
INJURED
#
Enter number: The producer assigned number for the injured party.
INJURED
Name & Address
Enter text: The name of a person that was injured in the incident or accident.
INJURED
Enter text: The first address line of the injured party.
INJURED
Enter text: The second address line of the injured party.
INJURED
Enter text: The city of the injured party.
INJURED
Enter code: The state or province of the injured party.
INJURED
Enter code: The postal code of the injured party.
INJURED
Home Phone
Enter number: The primary phone number of the injured party. As used here, this is the
home phone number.
INJURED
Business Phone
Enter number: The secondary phone number of the injured party. As used here, this is the
business phone number.
INJURED
Cell Phone
Enter number: The third phone number of the injured party. As used here, this is the cell
phone number.
INJURED
Insured Aircraft
Check the box (if applicable): Indicates if the injured party was in the insured's aircraft.
ACORD 7 (2009/05)
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Section Name
Field Name
Field and/or Section Description
INJURED
Other Aircraft
Check the box (if applicable): Indicates if the injured party was in an aircraft other than the
insured's aircraft at the time of the incident or accident.
INJURED
Other Checkbox
Check the box (if applicable): Indicates if the injured party was in a location other than
those listed.
INJURED
Other Description
Enter text: The location of the injured party at the time of the incident or accident.
INJURED
Age
Enter number: The age, at the time of the incident, of the injured party.
INJURED
Extent of Injury
Enter text: A brief description of the injury sustained by the injured party (e.g. broken left
leg).
INJURED
#
Enter number: The producer assigned number for the injured party.
INJURED
Name & Address
Enter text: The name of a person that was injured in the incident or accident.
INJURED
Enter text: The first address line of the injured party.
INJURED
Enter text: The second address line of the injured party.
INJURED
Enter text: The city of the injured party.
INJURED
Enter code: The state or province of the injured party.
INJURED
Enter code: The postal code of the injured party.
INJURED
Home Phone
Enter number: The primary phone number of the injured party. As used here, this is the
home phone number.
INJURED
Business Phone
Enter number: The secondary phone number of the injured party. As used here, this is the
business phone number.
INJURED
Cell Phone
Enter number: The third phone number of the injured party. As used here, this is the cell
phone number.
INJURED
Insured Aircraft
Check the box (if applicable): Indicates if the injured party was in the insured's aircraft.
INJURED
Other Aircraft
Check the box (if applicable): Indicates if the injured party was in an aircraft other than the
insured's aircraft at the time of the incident or accident.
INJURED
Other Checkbox
Check the box (if applicable): Indicates if the injured party was in a location other than
those listed.
INJURED
Other Description
Enter text: The location of the injured party at the time of the incident or accident.
INJURED
Age
Enter number: The age, at the time of the incident, of the injured party.
INJURED
Extent of Injury
Enter text: A brief description of the injury sustained by the injured party (e.g. broken left
leg).
INJURED
#
Enter number: The producer assigned number for the injured party.
INJURED
Name & Address
Enter text: The name of a person that was injured in the incident or accident.
INJURED
Enter text: The first address line of the injured party.
INJURED
Enter text: The second address line of the injured party.
INJURED
Enter text: The city of the injured party.
ACORD 7 (2009/05)
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Section Name
Field Name
Field and/or Section Description
INJURED
Enter code: The state or province of the injured party.
INJURED
Enter code: The postal code of the injured party.
INJURED
Home Phone
Enter number: The primary phone number of the injured party. As used here, this is the
home phone number.
INJURED
Business Phone
Enter number: The secondary phone number of the injured party. As used here, this is the
business phone number.
INJURED
Cell Phone
Enter number: The third phone number of the injured party. As used here, this is the cell
phone number.
INJURED
Insured Aircraft
Check the box (if applicable): Indicates if the injured party was in the insured's aircraft.
INJURED
Other Aircraft
Check the box (if applicable): Indicates if the injured party was in an aircraft other than the
insured's aircraft at the time of the incident or accident.
INJURED
Other Checkbox
Check the box (if applicable): Indicates if the injured party was in a location other than
those listed.
INJURED
Other Description
Enter text: The location of the injured party at the time of the incident or accident.
INJURED
Age
Enter number: The age, at the time of the incident, of the injured party.
INJURED
Extent of Injury
Enter text: A brief description of the injury sustained by the injured party (e.g. broken left
leg).
INJURED
#
Enter number: The producer assigned number for the injured party.
INJURED
Name & Address
Enter text: The name of a person that was injured in the incident or accident.
INJURED
Enter text: The first address line of the injured party.
INJURED
Enter text: The second address line of the injured party.
INJURED
Enter text: The city of the injured party.
INJURED
Enter code: The state or province of the injured party.
INJURED
Enter code: The postal code of the injured party.
INJURED
Home Phone
Enter number: The primary phone number of the injured party. As used here, this is the
home phone number.
INJURED
Business Phone
Enter number: The secondary phone number of the injured party. As used here, this is the
business phone number.
INJURED
Cell Phone
Enter number: The third phone number of the injured party. As used here, this is the cell
phone number.
INJURED
Insured Aircraft
Check the box (if applicable): Indicates if the injured party was in the insured's aircraft.
INJURED
Other Aircraft
Check the box (if applicable): Indicates if the injured party was in an aircraft other than the
insured's aircraft at the time of the incident or accident.
ACORD 7 (2009/05)
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Section Name
Field Name
Field and/or Section Description
INJURED
Other Checkbox
Check the box (if applicable): Indicates if the injured party was in a location other than
those listed.
INJURED
Other Description
Enter text: The location of the injured party at the time of the incident or accident.
INJURED
Age
Enter number: The age, at the time of the incident, of the injured party.
INJURED
Extent of Injury
Enter text: A brief description of the injury sustained by the injured party (e.g. broken left
leg).
INJURED
#
Enter number: The producer assigned number for the injured party.
INJURED
Name & Address
Enter text: The name of a person that was injured in the incident or accident.
INJURED
Enter text: The first address line of the injured party.
INJURED
Enter text: The second address line of the injured party.
INJURED
Enter text: The city of the injured party.
INJURED
Enter code: The state or province of the injured party.
INJURED
Enter code: The postal code of the injured party.
INJURED
Home Phone
Enter number: The primary phone number of the injured party. As used here, this is the
home phone number.
INJURED
Business Phone
Enter number: The secondary phone number of the injured party. As used here, this is the
business phone number.
INJURED
Cell Phone
Enter number: The third phone number of the injured party. As used here, this is the cell
phone number.
INJURED
Insured Aircraft
Check the box (if applicable): Indicates if the injured party was in the insured's aircraft.
INJURED
Other Aircraft
Check the box (if applicable): Indicates if the injured party was in an aircraft other than the
insured's aircraft at the time of the incident or accident.
INJURED
Other Checkbox
Check the box (if applicable): Indicates if the injured party was in a location other than
those listed.
INJURED
Other Description
Enter text: The location of the injured party at the time of the incident or accident.
INJURED
Age
Enter number: The age, at the time of the incident, of the injured party.
INJURED
Extent of Injury
Enter text: A brief description of the injury sustained by the injured party (e.g. broken left
leg).
INJURED
#
Enter number: The producer assigned number for the injured party.
INJURED
Name & Address
Enter text: The name of a person that was injured in the incident or accident.
INJURED
Enter text: The first address line of the injured party.
INJURED
Enter text: The second address line of the injured party.
INJURED
Enter text: The city of the injured party.
INJURED
Enter code: The state or province of the injured party.
INJURED
Enter code: The postal code of the injured party.
ACORD 7 (2009/05)
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Section Name
Field Name
Field and/or Section Description
INJURED
Home Phone
Enter number: The primary phone number of the injured party. As used here, this is the
home phone number.
INJURED
Business Phone
Enter number: The secondary phone number of the injured party. As used here, this is the
business phone number.
INJURED
Cell Phone
Enter number: The third phone number of the injured party. As used here, this is the cell
phone number.
INJURED
Insured Aircraft
Check the box (if applicable): Indicates if the injured party was in the insured's aircraft.
INJURED
Other Aircraft
Check the box (if applicable): Indicates if the injured party was in an aircraft other than the
insured's aircraft at the time of the incident or accident.
INJURED
Other Checkbox
Check the box (if applicable): Indicates if the injured party was in a location other than
those listed.
INJURED
Other Description
Enter text: The location of the injured party at the time of the incident or accident.
INJURED
Age
Enter number: The age, at the time of the incident, of the injured party.
INJURED
Extent of Injury
Enter text: A brief description of the injury sustained by the injured party (e.g. broken left
leg).
INJURED
#
Enter number: The producer assigned number for the injured party.
INJURED
Name & Address
Enter text: The name of a person that was injured in the incident or accident.
INJURED
Enter text: The first address line of the injured party.
INJURED
Enter text: The second address line of the injured party.
INJURED
Enter text: The city of the injured party.
INJURED
Enter code: The state or province of the injured party.
INJURED
Enter code: The postal code of the injured party.
INJURED
Home Phone
Enter number: The primary phone number of the injured party. As used here, this is the
home phone number.
INJURED
Business Phone
Enter number: The secondary phone number of the injured party. As used here, this is the
business phone number.
INJURED
Cell Phone
Enter number: The third phone number of the injured party. As used here, this is the cell
phone number.
INJURED
Insured Aircraft
Check the box (if applicable): Indicates if the injured party was in the insured's aircraft.
INJURED
Other Aircraft
Check the box (if applicable): Indicates if the injured party was in an aircraft other than the
insured's aircraft at the time of the incident or accident.
INJURED
Other Checkbox
Check the box (if applicable): Indicates if the injured party was in a location other than
those listed.
INJURED
Other Description
Enter text: The location of the injured party at the time of the incident or accident.
ACORD 7 (2009/05)
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Section Name
Field Name
Field and/or Section Description
INJURED
Age
Enter number: The age, at the time of the incident, of the injured party.
INJURED
Extent of Injury
Enter text: A brief description of the injury sustained by the injured party (e.g. broken left
leg).
INJURED
#
Enter number: The producer assigned number for the injured party.
INJURED
Name & Address
Enter text: The name of a person that was injured in the incident or accident.
INJURED
Enter text: The first address line of the injured party.
INJURED
Enter text: The second address line of the injured party.
INJURED
Enter text: The city of the injured party.
INJURED
Enter code: The state or province of the injured party.
INJURED
Enter code: The postal code of the injured party.
INJURED
Home Phone
Enter number: The primary phone number of the injured party. As used here, this is the
home phone number.
INJURED
Business Phone
Enter number: The secondary phone number of the injured party. As used here, this is the
business phone number.
INJURED
Cell Phone
Enter number: The third phone number of the injured party. As used here, this is the cell
phone number.
INJURED
Insured Aircraft
Check the box (if applicable): Indicates if the injured party was in the insured's aircraft.
INJURED
Other Aircraft
Check the box (if applicable): Indicates if the injured party was in an aircraft other than the
insured's aircraft at the time of the incident or accident.
INJURED
Other Checkbox
Check the box (if applicable): Indicates if the injured party was in a location other than
those listed.
INJURED
Other Description
Enter text: The location of the injured party at the time of the incident or accident.
INJURED
Age
Enter number: The age, at the time of the incident, of the injured party.
INJURED
Extent of Injury
Enter text: A brief description of the injury sustained by the injured party (e.g. broken left
leg).
INJURED
#
Enter number: The producer assigned number for the injured party.
INJURED
Name & Address
Enter text: The name of a person that was injured in the incident or accident.
INJURED
Enter text: The first address line of the injured party.
INJURED
Enter text: The second address line of the injured party.
INJURED
Enter text: The city of the injured party.
INJURED
Enter code: The state or province of the injured party.
INJURED
Enter code: The postal code of the injured party.
INJURED
Home Phone
Enter number: The primary phone number of the injured party. As used here, this is the
home phone number.
ACORD 7 (2009/05)
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Section Name
Field Name
Field and/or Section Description
INJURED
Business Phone
Enter number: The secondary phone number of the injured party. As used here, this is the
business phone number.
INJURED
Cell Phone
Enter number: The third phone number of the injured party. As used here, this is the cell
phone number.
INJURED
Insured Aircraft
Check the box (if applicable): Indicates if the injured party was in the insured's aircraft.
INJURED
Other Aircraft
Check the box (if applicable): Indicates if the injured party was in an aircraft other than the
insured's aircraft at the time of the incident or accident.
INJURED
Other Checkbox
Check the box (if applicable): Indicates if the injured party was in a location other than
those listed.
INJURED
Other Description
Enter text: The location of the injured party at the time of the incident or accident.
INJURED
Age
Enter number: The age, at the time of the incident, of the injured party.
INJURED
Extent of Injury
Enter text: A brief description of the injury sustained by the injured party (e.g. broken left
leg).
INJURED
#
Enter number: The producer assigned number for the injured party.
INJURED
Name & Address
Enter text: The name of a person that was injured in the incident or accident.
INJURED
Enter text: The first address line of the injured party.
INJURED
Enter text: The second address line of the injured party.
INJURED
Enter text: The city of the injured party.
INJURED
Enter code: The state or province of the injured party.
INJURED
Enter code: The postal code of the injured party.
INJURED
Home Phone
Enter number: The primary phone number of the injured party. As used here, this is the
home phone number.
INJURED
Business Phone
Enter number: The secondary phone number of the injured party. As used here, this is the
business phone number.
INJURED
Cell Phone
Enter number: The third phone number of the injured party. As used here, this is the cell
phone number.
INJURED
Insured Aircraft
Check the box (if applicable): Indicates if the injured party was in the insured's aircraft.
INJURED
Other Aircraft
Check the box (if applicable): Indicates if the injured party was in an aircraft other than the
insured's aircraft at the time of the incident or accident.
INJURED
Other Checkbox
Check the box (if applicable): Indicates if the injured party was in a location other than
those listed.
INJURED
Other Description
Enter text: The location of the injured party at the time of the incident or accident.
INJURED
Age
Enter number: The age, at the time of the incident, of the injured party.
ACORD 7 (2009/05)
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Section Name
Field Name
Field and/or Section Description
INJURED
Extent of Injury
Enter text: A brief description of the injury sustained by the injured party (e.g. broken left
leg).
INJURED
#
Enter number: The producer assigned number for the injured party.
INJURED
Name & Address
Enter text: The name of a person that was injured in the incident or accident.
INJURED
Enter text: The first address line of the injured party.
INJURED
Enter text: The second address line of the injured party.
INJURED
Enter text: The city of the injured party.
INJURED
Enter code: The state or province of the injured party.
INJURED
Enter code: The postal code of the injured party.
INJURED
Home Phone
Enter number: The primary phone number of the injured party. As used here, this is the
home phone number.
INJURED
Business Phone
Enter number: The secondary phone number of the injured party. As used here, this is the
business phone number.
INJURED
Cell Phone
Enter number: The third phone number of the injured party. As used here, this is the cell
phone number.
INJURED
Insured Aircraft
Check the box (if applicable): Indicates if the injured party was in the insured's aircraft.
INJURED
Other Aircraft
Check the box (if applicable): Indicates if the injured party was in an aircraft other than the
insured's aircraft at the time of the incident or accident.
INJURED
Other Checkbox
Check the box (if applicable): Indicates if the injured party was in a location other than
those listed.
INJURED
Other Description
Enter text: The location of the injured party at the time of the incident or accident.
INJURED
Age
Enter number: The age, at the time of the incident, of the injured party.
INJURED
Extent of Injury
Enter text: A brief description of the injury sustained by the injured party (e.g. broken left
leg).
INJURED
#
Enter number: The producer assigned number for the injured party.
INJURED
Name & Address
Enter text: The name of a person that was injured in the incident or accident.
INJURED
Enter text: The first address line of the injured party.
INJURED
Enter text: The second address line of the injured party.
INJURED
Enter text: The city of the injured party.
INJURED
Enter code: The state or province of the injured party.
INJURED
Enter code: The postal code of the injured party.
INJURED
Home Phone
Enter number: The primary phone number of the injured party. As used here, this is the
home phone number.
INJURED
Business Phone
Enter number: The secondary phone number of the injured party. As used here, this is the
business phone number.
ACORD 7 (2009/05)
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Section Name
Field Name
Field and/or Section Description
INJURED
Cell Phone
Enter number: The third phone number of the injured party. As used here, this is the cell
phone number.
INJURED
Insured Aircraft
Check the box (if applicable): Indicates if the injured party was in the insured's aircraft.
INJURED
Other Aircraft
Check the box (if applicable): Indicates if the injured party was in an aircraft other than the
insured's aircraft at the time of the incident or accident.
INJURED
Other Checkbox
Check the box (if applicable): Indicates if the injured party was in a location other than
those listed.
INJURED
Other Description
Enter text: The location of the injured party at the time of the incident or accident.
INJURED
Age
Enter number: The age, at the time of the incident, of the injured party.
INJURED
Extent of Injury
Enter text: A brief description of the injury sustained by the injured party (e.g. broken left
leg).
INJURED
#
Enter number: The producer assigned number for the injured party.
INJURED
Name & Address
Enter text: The name of a person that was injured in the incident or accident.
INJURED
Enter text: The first address line of the injured party.
INJURED
Enter text: The second address line of the injured party.
INJURED
Enter text: The city of the injured party.
INJURED
Enter code: The state or province of the injured party.
INJURED
Enter code: The postal code of the injured party.
INJURED
Home Phone
Enter number: The primary phone number of the injured party. As used here, this is the
home phone number.
INJURED
Business Phone
Enter number: The secondary phone number of the injured party. As used here, this is the
business phone number.
INJURED
Cell Phone
Enter number: The third phone number of the injured party. As used here, this is the cell
phone number.
INJURED
Insured Aircraft
Check the box (if applicable): Indicates if the injured party was in the insured's aircraft.
INJURED
Other Aircraft
Check the box (if applicable): Indicates if the injured party was in an aircraft other than the
insured's aircraft at the time of the incident or accident.
INJURED
Other Checkbox
Check the box (if applicable): Indicates if the injured party was in a location other than
those listed.
INJURED
Other Description
Enter text: The location of the injured party at the time of the incident or accident.
INJURED
Age
Enter number: The age, at the time of the incident, of the injured party.
INJURED
Extent of Injury
Enter text: A brief description of the injury sustained by the injured party (e.g. broken left
leg).
INJURED
#
Enter number: The producer assigned number for the injured party.
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Section Name
Field Name
Field and/or Section Description
INJURED
Name & Address
Enter text: The name of a person that was injured in the incident or accident.
INJURED
Enter text: The first address line of the injured party.
INJURED
Enter text: The second address line of the injured party.
INJURED
Enter text: The city of the injured party.
INJURED
Enter code: The state or province of the injured party.
INJURED
Enter code: The postal code of the injured party.
INJURED
Home Phone
Enter number: The primary phone number of the injured party. As used here, this is the
home phone number.
INJURED
Business Phone
Enter number: The secondary phone number of the injured party. As used here, this is the
business phone number.
INJURED
Cell Phone
Enter number: The third phone number of the injured party. As used here, this is the cell
phone number.
INJURED
Insured Aircraft
Check the box (if applicable): Indicates if the injured party was in the insured's aircraft.
INJURED
Other Aircraft
Check the box (if applicable): Indicates if the injured party was in an aircraft other than the
insured's aircraft at the time of the incident or accident.
INJURED
Other Checkbox
Check the box (if applicable): Indicates if the injured party was in a location other than
those listed.
INJURED
Other Description
Enter text: The location of the injured party at the time of the incident or accident.
INJURED
Age
Enter number: The age, at the time of the incident, of the injured party.
INJURED
Extent of Injury
Enter text: A brief description of the injury sustained by the injured party (e.g. broken left
leg).
Edition
Date
The edition identifier of the form including the form number and edition (the date is
typically formatted YYYY/MM).
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