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P L E AS E R E M E M B E R

You must return this form to:

DO NOT send to your medical

USA Cycling Insurance is an

BMI Benefits, LLC

provider for completion

excess policy and may carry

PO Box 511

YOU MUST FILL IT OUT

a DEDUCTIBLE.

USA Cycling

76 Main St.

YOU MUST SIGN this form.

Keep a copy for your files.

Matawan, NJ 07747

We MUST have a copy of your

Please note that all claims

Case Report

Phone: 800-445-3126

USA Cycling membership card to

will be verified by BMI with

For registered

Fax: 732-583-9610

USA Cycling prior to set up.

process your claim.

Email:

Cyclists/Officials/Volunteers

Mark all that apply. Complete relevant blanks.

Date of Incident:

Time of Incident:

Date of Event: ______________________

Was the injured person riding:

 Single Bike  Tandem Bike

USAC License Number: _________________________________________

Does the injured person have medical insurance?

 Yes

 No

If Yes, name of insurance company and policy.

Insurance company name:

Policy name:_______________________________________

Race Name:

Permit Number : ____________________________________

Promoter’s Name:

Promoting Club: ____________________________________

INJURED PERSON INFORMATION:

 Participant

 Volunteer  Official  Other ________________________________________________________

TYPE OF EVENT



Road

Was the injured person wearing a helmet at the time of the accident?  Yes  No



Mountain Bike



 Annual License Rider

 One Day

Track



Collegiate

Last Name:

___

First Name:

___

MI: ___________



BMX



Address: _____________________________________________________________________________________________

Cyclocross



Pro Road

City:

State:

Zip: ___________________



Non-competitive

Phone: (

)

Social Security #: __________________________________

CATEGORY



Age:

Date of Birth:

Gender:

Male

Female



Email: ___________________________________________ Employer’s Name: _____________________________________



INCIDENT LOCATION

RIDER ACTIVITY

CAUSE

DISPOSITION



Assault

Report only

Off-Road

Turning right



Parking lot

Fall

Released to parent

Pro



Turning left



Registration area

Caught in extremity

Police



Being passed



ROAD TYPE

Restroom/locker room

Animal involvement

Ambulance to hospital



Passing



Paved

Premises/grounds

Collision (with parked car)

Refer to doctor



Street

Intersection

Collision (with moving car)

Refer to hospital/clinic



Dirt



Highway

Collision (with object)

First Aid



Straight



Gravel



Rural road

Collision (with participant)

Continued riding



Off property

Collision (with pedestrian)



Asphalt

Refused treatment



Auto/property (with parked car)



Velodrome/track



Off-Road



Overexertion



Equipment malfunction

ROAD CONDITIONS



Wet



Death

Amputation

Abrasion

Burn

PRIMARY INJURY



Allergy

Concussion

Heat exhaustion

Hypertension

Laceration

Dry



Fracture

Nausea

Electrical shock

Cardiac arrest

Contusion



Ice



Seizures

Drowning

Pain

Illness

Insect bite



Dislocation

Strain/Sprain

Stroke

Frostbite

Other: ______________________________



Hand (L) (R)

Shoulder (L) (R)

Head

Torso

Tooth

BODY PART INJURED



Eye (L) (R)

Arm (L) (R)

Foot (L) (R)

Face

Internal

Ear (L) (R)



Ankle (L) (R)

Hip (L) (R)

Leg (L) (R)

Mouth

Back

Finger or Toe



Knee (L) (R)

Wrist (L) (R)

Elbow (L) (R)

Neck

Nose

Other: ____________

Describe how the incident happened: _________________________________________________________________________________________

________________________________________________________________________________________________________________________

Signature of the Injured Party: ____________________________________________________________ Date: _____________________________

Accident Insurance Claim Form - Usa Cycling Case Report For Registered Cyclists/officials/volunteers

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