Complete details in spaces provided below then click the 'Submit' button to automatically send your Accident Report Form to the NARGC.
Alternatively, you can download the Accident Report Form by clicking here.

---

Accident Report Form
General Details
Fund Subscriber (Responsible)
Address
Phone
Date of birth (dd/mm/yy)
Name of Gun Club to which you belong
County Body to which your Club is affiliated
State Fund Membership Card Number
State date on which protection commenced(dd/mm/yy)
How long have you been shooting?
Insurance Policies you may hold
Householder
Insurer (Householder)
Policy number (Householder)
Renewal date (Householder)
Farmer liability
Insurer (Farmer liability)
Policy number (Farmer liability)
Renewal date (Farmer liability)
insure you against shooting/dog liability?
If yes, state which and elaborate
The third party
Third Party Name
Third Party Address
Third Party Telephone Number
Approximate age
Occupation
Marital Status
If married, number of children
Third Party is a Member of a Gun Club
If yes, state the name of the club
State your relationship with Third Party (if any)
Accident
Place of Occurence
Date of Occurence
Time of Occurrence (state a.m. or p.m.)
In the following provide copious detail of
a. The circumstances leading up to the incident
b. How the incident actually occurred
c. What took place in the immediate aftermath
If possible send a sketch to the NARGC separatedly
Name of Witness (if any)
Witness Address
Witness Telephone Number
Name of Second Witness (if any)
Second Witness Address
Second Witness Telephone Number
To whom was this incident first reported and when
If this Incident relates to a Shooting Accident
Name of gun involved in incident
Model
How old is the gun
Type of cartridge involved and No.
Distance from Target (yards)
If this Incident relates to a Dog Attack
Breed of dog
Age of dog
Sex (tick appropriate box)
Male
Female
The dog is I.K.C. registered
Other Details
Comments