CRITICAL FORM

TIME-SENSITIVE AND URGENT

This form must be submitted by XX:XX or you will be ineligible to be able to receive your insurance benefits.

This is a hard deadline and there are absolutely no exceptions that can be granted. If you are unable to submit this form in completion, we will not be able to extend coverage for your current emergency.

FULL LEGAL NAME (REQUIRED):

PREFFERED NAME (REQUIRED):

GENDER IDENTITY (REQUIRED):

LOCATION OF EMERGENCY (REQUIRED):

LOCATION OF YOUR FIRST KISS (REQUIRED):

MAGIC TYPE (REQUIRED):

MAGICAL ALLERGIES (LIFE-THREATENING):

DESCRIPTION OF EMERGENCY (REQUIRED):

HISTORY OF RELATED INCIDENTS (REQUIRED):

VITALS (REQUIRED) HEIGHT (IN): PHYSICAL FORM: BODY TEMPERATURE (°K): WING FLUTTER RATE (FLUTTERS/MIN): REMAINING MANA (%): FAVORITE SONG IN HIGH SCHOOL:

EMERGENCY CONTACT (REQUIRED): EMERGENCY CONTACT NAME: EMERGENCY CONTACT METHOD OF CONTACT: CONTACT INSTRUCTIONS: RELATIONSHIP TO CONTACT: HOW YOU FEEL ABOUT YOUR CURRENT RELATIONSHIP TO CONTACT: HOW YOU MIGHT WANT TO STRENGTHEN THIS RELATIONSHIP IN THE FUTURE: FAVORITE MEMORY WITH CONTACT:

OTHER COMMENTS FOR INSURANCE AGENCY (required):