Cycling BC Accident Report Form

Note that only accidents reported as “major” will trigger an insurance claim. These include fractures, dislocations, concussions, severed tendons, dental damage or any injury that requires hospitalization. Accidents marked as “minor” are reviewed and kept on file for record keeping purposes only.

Accidents reports for “major” incidents will be forwarded to Cycling BC’s insurance underwriter to begin the claim process. Note that the underwriter will also require their accident report form to be filled out and approved by a physician and Cycling BC.

Accident Report

If an injury takes place, submit this report within 7 days of the accident.

Incident Level
Injured: Full Name*
Injured: Phone Number*
Injured Email Address*
Injured: Cycling BC Membership #
Date of Accident:*
MM slash DD slash YYYY
Time of Accident:*

Hours :

Minutes
Event Type:*
Event / Activity Name:*
Injury: Summary*
Injury: Full Description
Describe the extent of the injury and the situation leading up to the accident
First Aid Attendant Name
First Aid Attendant Emal
Witness: Full Name*
Witness: Phone Number
Event Organizer: Full Name
Event Organizer: Phone Number
Was First Aid administered at the scene?
Was an ambulance called to the scene?
What hospital was the Injured Person taken to:
Please list any other relevant information:
Photo / Document Upload
Optional - 24mb max
Max. file size: 32 MB.
Digital Signature*
This form must be completed as much as possible, and be submitted to Cycling BC within 7 days of the injury. If available, please attach any reports from the first responder. This document and its contents are privileged; they were prepared in anticipation of litigation. For additional correspondence, email [email protected]
- Yes - I have completed this form to the best of my ability
Email of Person Submitting Report*
Email
This field is for validation purposes and should be left unchanged.

Save and Continue Later