Cycling BC Accident Report Form

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:*
Date Format: MM slash DD slash YYYY
Time of Accident:*

HH :

MM
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
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 insurance@cyclingbc.net.
- Yes - I have completed this form to the best of my ability
Email of Person Submitting Report*
Phone
This field is for validation purposes and should be left unchanged.

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