INCIDENT REPORTING INSTRUCTIONS
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1 INSURING AMERICA'S PASTIMES AND FUTURE TIMES INCIDENTREPORTINGINSTRUCTIONS WheneveranAccidentOccurs: AnIncidentReportformmustbecompletedimmediatelyafteranaccidentoccursandmailedor faxedtoamericanspecialtyinsurance&riskservices,inc.asindicatedbelow.thisholdstrue whetherthepersoninvolvedisaparticipantoraspectator,orwhetherornotyoufeelthe incidentwillresultinaclaim. Althoughyoumaynothavesufficientinformationtoinitiallyanswerallquestions,itisimportant thattheformbecompletedasfullyaspossibleatthetimeoftheaccident.donotdelay sendinginthereportform;anincompleteformisbetterthannoneatall.becertaintoinclude yournameanddaytimetelephonenumberwhereindicatedontheform. Theformcontainssectionstocaptureinformationregardinginjurytopersons,damageto property,andaccidentsinvolvingautos. IfyouhaveanyquestionsorneedassistanceregardingthecompletionoftheIncidentReport form,pleasecallamericanspecialtyat MailorfaxthecompletedIncidentReportto: AMERICANSPECIALTYINSURANCE&RISKSERVICES,INC. Attn:ClaimsDepartment PostOfficeBox459 Roanoke,Indiana Fax:(260) INADDITION,INCASEOFSERIOUSINJURYTOAPARTICIPANTORASPECTATOR,itisimportant thatyouimmediatelynotifyamericanspecialtybycalling (ifafterstandard businesshours,simplyfollowtheautomatedinstructionsforemergencyclaimsreporting).this hotlineisactive24hoursaday,365daysayear.
2 FOR BODILY INJURY Date of Incident: Time of Incident: AM / PM Does the Injured Person Have Other Medical Insurance? Yes No If injured person is a League member, identify: If yes, please provide: League Club Name of company: Club Policy #: Injured Person: Club Member Non-Member Participant Did This Take Place During: Club Ride Special Event Race Volunteer Pedestrian Other Time Trial Conditioning Event Bicycle Education Course Fundraiser If during a Special Event, list name of event: Was the injured person wearing a helmet at the time of the accident? Yes No Name of League Club putting on the Special Event: Was the injured person riding: Tandem Bike Single Bike INJURED PERSON INFORMATION Last Name First Mid. Telephone Number ( ) Single Married Address Social Security Number (optional): City Employer Age D.O.B. Male Female Employer GUARDIAN/PARENT (if injured person is a minor) Last Name First Mid. Telephone Number ( ) Address City State Zip SUSPECTED PRE-EXISTING CONDITION: Yes No Off Road Parking Lot Registration Area Restrooms/Locker Rooms Premises/Grounds Turning right Turning left Being passed INCIDENT LOCATION INCIDENT WEATHER CONDITIONS City Street Sunny Raining Highway Foggy Snowing Rural Road Cloudy Off Property Rest Stop RIDER ACTIVITY Passing Intersection Straight Assault/Sexual Assault/Non-Sexual Fall (different level) Fall (same level) Caught in, on, between Animal/Insect Bite/Sting Collision (with parked car) Collision (with moving car) Collision (with object/animal) Overexertion Eligibility Trip/fall Slip/fall Slip, bodily reaction Chased by dog Bit by dog Collision (participant/ participant) Wet Icy ROAD CONDITIONS Dry Collision Auto/property (also ROAD TYPE CLASSIFICATION (participant/pedestrian) complete reverse side of Paved Dirt Minor injury or illness Non-injury Struck by falling/flying this form) Gravel Serious injury or illness object PRIMARY INJURY BODY PARTY INJURED DISPOSITION Nausea Stroke Burn Death Pain Illness Cardiac Arm (L/R) Tooth Head Released to parent Refusal of care Refer to doctor Medical attention EMS transport Continued riding Allergy Amputation Abrasion Laceration Drowning Hypertension Cold Injury Seizures Strain/Sprain Dislocation Electrical Shock Foreign Body Fracture Heat Exhaustion Sting/bite Contusion Concussion Tooth/Mouth DESCRIBE HOW THE INCIDENT OCCURRED: Eye (L/R) Nose Neck Ear (L/R) Knee (L/R) Internal Shoulder (L/R) Elbow (L/R) Wrist (L/R) Torso Back Face Leg (L/R) Ankle (L/R) Hip (L/R) Foot (L/R) Hand (L/R) Finger or Toe Police Ambulance Report Only Patient requested EMS transport Released to personal vehicle Refer to hospital/clinic WITNESS INFORMATION NAME ADDRESS TELEPHONE NUMBER 1. ( ) 2. ( ) Signature of Ride Leader or Official (with no relationship to claimant) Date Phone Number Revised 1/28/2013 DME #481202
3 FOR AUTO ACCIDENT AND PROPERTY DAMAGE IF THE INJURY OR PROPERTY DAMAGE WAS THE RESULT OF AN AUTO ACCIDENT, PLEASE COMPLETE THIS SECTION: PERSON DRIVING THE AUTO: Injured Not injured OWNER OF THE AUTO: MAKE/MODEL/YEAR OF AUTO: LIST NAMES AND ADDRESSES OF ALL PASSENGERS IN THE AUTO: Injured Not injured Injured Not injured NOTE: PLEASE USE THE REVERSE SIDE OF THIS FORM TO PROVIDE INJURY INFORMATION. A LIST OF ALL PASSENGERS AND INJURY INFORMATION FOR ALL INJURED PERSONS SHOULD BE PROVIDED; PLEASE USE ADDITIONAL INCIDENT REPORT FORMS OR SEPARATE SHEETS OF PAPER, IF NECESSARY. PURPOSE OF TRIP: NAME OF POLICE DEPARTMENT WHICH INVESTIGATED THE ACCIDENT: IF THE ACCIDENT INVOLVED A COLLISION WITH ANOTHER AUTOMOBILE, PLEASE COMPLETE THIS SECTION: PERSON DRIVING OTHER AUTO: Injured Not-injured OWNER OF OTHER AUTO: MAKE/MODEL/YEAR OF OTHER AUTO: LIST NAMES AND ADDRESSES OF ALL PASSENGERS IN OTHER AUTO: Injured Not injured Injured Not injured (Attach separate sheet of paper, if necessary.) IF THE ACCIDENT INVOLVED PROPERTY DAMAGE (OTHER THAN AUTOMOBILES), PLEASE COMPLETE THIS SECTION: If property was damaged, please supply a description of the property and list the owner. (If an auto accident, see above sections.) Description of property: Description of damage: Owner's name and address: Owner's telephone number: ( ) (day) ( ) (evening) Revised 1/28/2013 DME #481202
4 FOR AUTO ACCIDENT AND PROPERTY DAMAGE IF THE INJURY OR PROPERTY DAMAGE WAS THE RESULT OF AN AUTO ACCIDENT, PLEASE COMPLETE THIS SECTION: PERSON DRIVING THE AUTO: Injured Not injured OWNER OF THE AUTO: MAKE/MODEL/YEAR OF AUTO: LIST NAMES AND ADDRESSES OF ALL PASSENGERS IN THE AUTO: Injured Not injured Injured Not injured NOTE: PLEASE USE THE REVERSE SIDE OF THIS FORM TO PROVIDE INJURY INFORMATION. A LIST OF ALL PASSENGERS AND INJURY INFORMATION FOR ALL INJURED PERSONS SHOULD BE PROVIDED; PLEASE USE ADDITIONAL INCIDENT REPORT FORMS OR SEPARATE SHEETS OF PAPER, IF NECESSARY. PURPOSE OF TRIP: NAME OF POLICE DEPARTMENT WHICH INVESTIGATED THE ACCIDENT: IF THE ACCIDENT INVOLVED A COLLISION WITH ANOTHER AUTOMOBILE, PLEASE COMPLETE THIS SECTION: PERSON DRIVING OTHER AUTO: Injured Not-injured OWNER OF OTHER AUTO: MAKE/MODEL/YEAR OF OTHER AUTO: LIST NAMES AND ADDRESSES OF ALL PASSENGERS IN OTHER AUTO: Injured Not injured Injured Not injured (Attach separate sheet of paper, if necessary.) IF THE ACCIDENT INVOLVED PROPERTY DAMAGE (OTHER THAN AUTOMOBILES), PLEASE COMPLETE THIS SECTION: If property was damaged, please supply a description of the property and list the owner. (If an auto accident, see above sections.) Description of property: Description of damage: Owner's name and address: Owner's telephone number: ( ) (day) ( ) (evening) DME #481202
5 AMERICANSPECIALTY EMERGENCYCLAIMSSERVICE (24Hours/7DaysaWeek) ForAllClaimsEmergencies PleaseimmediatelyreportbyPHONEallincidentsthat resultinseriousinjuryordeath. PleasecompleteanIncidentReportformforANY incidentthatresultsindeath,seriousinjuryand/or bodilyinjury,automobile,orpropertydamage,and forwardviamailorfaxthecompletedformto: AMERICANSPECIALTYINSURANCE&RISKSERVICES,INC. PostOfficeBox459 Roanoke,IN Fax:(260) DME
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