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INCIDENT REPORTING INSTRUCTIONS
Whenever an Accident Occurs:
An Incident Report form must be completed immediately after an accident occurs
and mailed or faxed to American Specialty Insurance & Risk Services, Inc. as
indicated below. This holds true whether the person involved is a participant or a
spectator, or whether or not you feel the incident will result in a claim.
Although you may not have sufficient information to initially answer all questions,
it is important that the form be completed as fully as possible at the time of the
accident. Do not delay sending in the report form; an incomplete form is better
than none at all. Be certain to include your name and daytime telephone number
where indicated on the form.
The form contains sections to capture information regarding injury to persons,
damage to property, and accidents involving autos.
If you have any questions or need assistance regarding the completion of the
Incident Report form, please call American Specialty at 1-800-245-2744.
Mail or fax the completed Incident Report to:
AMERICAN SPECIALTY INSURANCE & RISK SERVICES, INC.
Attn: Claims Department
Post Office Box 459
Roanoke, Indiana 46783-0459
Fax: (260) 673-1291
IN ADDITION, IN CASE OF SERIOUS INJURY TO A PARTICIPANT OR A
SPECTATOR, it is important that you immediately notify American Specialty by
calling 1-800-566-7941 (if after standard business hours, simply follow the
automated instructions for emergency claims reporting). This hotline is active 24
hours a day, 365 days a year.
AMERICAN SPECIALTY INSURANCE & RISK SERVICES, INC.
ATTN: CLAIMS DEPARTMENT
POST OFFICE BOX 459
ROANOKE, IN 46783
PHONE: 800-566-7941 FAX: 260-673-1291
Date of Incident:
Time of Incident:
If injured person is an L.A.B. member, identify:
L.A.B. Club Name:
Club Address:
Does the Injured Person Have Other Medical Insurance? oYes oNo
If yes, please provide:
Name of company:
Policy #:
AM / PM
Injured Person: o Club Member o Non-Member o Participant o Volunteer
o Pedestrian o Other_
Was the injured person wearing a helmet at the time of the accident? o Yes o No
Was the injured person riding: o Tandem Bike
Did This Take Place During: o Club Ride o Special Event
o Race o Conditioning Event o Fundraiser
If during a Special Event, list name of event:
Name of L.A.B. Club putting on the Special Event:
o Time Trial
o Single Bike
INJURED PERSON INFORMATION
Last Name
Address
City
Age
First
Mid.
D.O.B.
o Male o Female
Telephone Number (
Social Security Number:
Employer Name:
Employer Address:
)
Telephone Number (
State
)
o Single o Married
GUARDIAN/PARENT (if injured person is a minor)
Last Name
Address
First
Mid.
City
SUSPECTED PRE-EXISTING CONDITION:
INCIDENT LOCATION
o Off Road
o City Street
o Parking Lot
o Highway
o Registration Area
o Rural Road
o Restrooms/Locker Rooms
o Off Property
o Premises/Grounds
o Rest Stop
RIDER ACTIVITY
o Turning right
o Passing
o Turning left
o Intersection
o Being passed
o Straight
CLASSIFICATION
o Minor injury or illness o Non-injury
o Serious injury or illness
PRIMARY INJURY
o Allergy
o Dislocation
o Amputation
o Electrical Shock
o Abrasion
o Foreign Body
o Laceration
o Fracture
o Drowning
o Heat Exhaustion
o Hypertension
o Sting/bite
o Cold Injury
o Contusion
o Seizures
o Concussion
o Strain/Sprain
o Tooth/Mouth
o Nausea
o Stroke
o Burn
o Death
o Pain
o Illness
o Cardiac
Zip
o Yes o No
INCIDENT
o Assault/Sexual
o Overexertion
o Assault/Non-Sexual
o Eligibility
o Fall (different level)
o Trip/fall
o Fall (same level)
o Slip/fall
o Caught in, on, between
o Slip, bodily reaction
o Animal/Insect Bite/Sting
o Chased by dog
o Collision (with parked car)
o Bit by dog
o Collision (with moving car)
o Collision (with object/animal)
o Collision (participant/participant
o Collision (participant/pedestrian)
o Struck by falling/flying object
o Auto/property (also complete reverse side)
o Eye (L/R)
o Nose
o Neck
o Ear (L/R)
o Knee (L/R)
o Internal
Shoulder (L/R)
o Elbow (L/R)
o Wrist (L/R)
BODY PARTY INJURED
o Torso
o Back
o Face
o Leg (L/R)
o Ankle (L/R)
o Hip (L/R) o
o Foot (L/R)
o Hand (L/R)
o Finger or Toe
o Arm (L/R)
o Tooth
o Head
o Sunny
o Foggy
o Cloudy
o Wet
o Icy
WEATHER CONDITIONS
o Raining
o Snowing
ROAD CONDITIONS
o Dry
ROAD TYPE
o Dirt
o Paved
o Gravel
DISPOSITION
o Released to parent
o Police
o Refusal of care
o Ambulance
o Refer to doctor
o Report Only
o Medical attention
o EMS transport
o Continued riding
o Patient requested EMS transport
o Released to personal vehicle
o Refer to hospital/clinic
DESCRIBE HOW THE INCIDENT OCCURRED:
WITNESS INFORMATION
NAME
ADDRESS
1.
2.
TELEPHONE NUMBER
(
(
)
)
Signature of Ride Leader or Official (with no relationship to claimant)
Date
Phone Number
DME #481202