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Notification of Claim for Scuba Medic Policies FORM NOC1
Please complete this from and send with any accompanying medical report to Northcott Global Solutions Ltd.
Email [email protected]
Patient Information
Patient Name Age
Telephone Email 
Address
Incident Date
Dive Centre / Resort
Name
Divers Certification / Qualification
Total number of dives since certifying
DIN/NIF or Passport Number Insurance Policy ID
Treatment Facility
Name Physician

Initial Symptoms, Condition
Muscular Weakness Paraesthesia upper limbs Paraesthesia lower limbs Visual Troubles Auditory troubles
Sphincter troubles Cerebral signs Cardio-respiratory arrest Breath hold accident Near drowning
Pain Cutaneous signs Trauma Marine life injury Vertigo
Cardiovascular signs Metabolic signs Confused Fatigue/Malaise Extreme fatigue
Unconscious Conscious Semi-conscious Worsening Spontaneous healing
Stable Itching Respiratory troubles Paralysis upper limbs Paralysis lower limbs
Other 
Details of Dive
Max Depth Total Dive Time
Deco stops omitted First dive of day Repetitive Dive Multiday diving Rapid ascent
Table diving Panic Pre/Post dive stress Alcohol intake pre-dive Computer diving
Technical diving Equipment Failure Flying after diving Air diving Nitrox diving
Trimix Novice Diver Experienced diver Try dive/Discover SCUBA Instructor / guide
Treatment Plan
Oxygen First Aid   Oxygen During Transport
Patient on arrival at treatment
facility		 Initial hyperbaric therapy
protocol		 Result after Initial hyperbaric Treatment

 
Final Diagnosis
Documents
Initial Medical Report Follow up medical report
Post chamber treatment report Copy of Patients Policy certificate
GOP Required
Estimate Cost