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BIKETOWN Crash Report Form
If you have been involved in a crash or have sustained an injury involving a BIKETOWN bicycle, please complete this form as soon as possible to the best of your ability. You will be prompted for the following information:

1. Your name and contact information.
2. Information about the crash.
3. Police contact information and report number if applicable.
4. Any injuries you suffered and subsequent medical treatment.
5. Damage to the bicycle or other party.
6. Names and contact information for witnesses and other involved parties.

When you submit the form, a confirmation message will be sent to you, and a notification message will be sent to BIKETOWN staff. The confirmation message will contain a link allowing you to edit your submission.

If you have any questions, or you would prefer to complete this form on paper, please contact customerservice@biketownpdx.com.

Your Information
First Name *
Your answer
Last Name *
Your answer
Phone Number *
Your answer
Email *
Your answer
Mailing Address *
Your answer
BIKETOWN Membership Type
Bike Rental Information
Card Number
Your answer
Date of BIKETOWN Rental
MM
/
DD
/
YYYY
Time of BIKETOWN Rental
Time
:
Hub Bike was Rented From
For help identifying the hub name go to http://www.biketownpdx.com/map, or click on the Rentals tab of your BIKETOWN member profile at https://www.biketownpdx.com/XX.
Your answer
Bike and Property Damage
What happened to the bicycle following the crash? *
Please describe damage sustained to the bicycle as a result of the crash.
Please indicate "NA" or "unknown" when applicable
Your answer
Please describe any other property damage that occurred as a result of the crash.
Please indicate "NA" or "unknown" when applicable.
Your answer
Crash Information
Date of Crash *
MM
/
DD
/
YYYY
Estimated time of crash *
Time
:
Location of crash *
Please indicate the intersection closest to the site of the crash.
Your answer
Type of crash *
Was crash a hit and run?
Were you wearing a helmet at the time of the crash?
Crash description *
Please describe the events and conditions before, during, and following the crash, to the best of your ability.
Your answer
Were there any traffic violations or fines by any involved party to your knowledge? Please list and explain.
Your answer
Police and Emergency Responders' Information
Did any of the following respond to the crash site? *
Check all that apply
Required
Were any citations issued to you or other parties? *
Was a police report filed? *
Officer's name, badge number, precinct, and contact information.
Your answer
Please provide the police report number and/or describe the citations issued to you or to other parties.
Your answer
Injuries and Medical Treatment
Were you injured in the crash? *
Did you receive medical treatment or did you visit a hospital as a result of the crash? *
If you were injured, please describe the injuries you suffered.
Your answer
Please describe the medical treatment you received, and indicate the hospital or medical professional who provided it.
Your answer
Driver and Vehicle Information
Was motor vehicle involved in the crash? *
Driver's Personal Information
First Name
Your answer
Last Name
Your answer
Phone Number
Your answer
Gender
Driver's date of birth
MM
/
DD
/
YYYY
Address
Your answer
Driver's License State and Number
Your answer
Driver's Insurance Information
Driver's insurance carrier
Your answer
Phone number of insurance carrier
Your answer
Driver's insurance policy number
Your answer
Vehicle Information
Vehicle Type
Vehicle year, make, and model
Your answer
Vehicle plate state and number
Your answer
Please describe any damage to the vehicle that resulted from the crash
Your answer
Was the vehicle towed? Is the vehicle operable?
Your answer
Passenger Information
Number of vehicle occupants at time of crash
Your answer
Were the driver or passengers injured? Please explain.
Your answer
Passenger Information
Please list the name, age, address, phone number, injuries and any additional information for each passenger.
Your answer
Witnesses and Other Involved Persons Information
If there were other persons with knowledge of the crash, personal injury, or property damage, please provide as much of the following information as possible.
Witness/Involved #1
Witness/Involved #1 Role
Please describe this person's role in the crash.
Witness/Involved #1 - Name
Your answer
Witness/Involved #1 - Address
Your answer
Witness/Involved #1 - Phone
Your answer
Witness/Involved #1 - Email
Your answer
Please provide a more detailed description of this Witness/Involved's involvement in the crash.
Your answer
Witness/Involved #2
Witness/Involved #2 - role
Witness/Involved #2 - Name
Your answer
Witness/Involved #2 - Address
Your answer
Witness/Involved #2 - Email
Your answer
Witness/Involved #2 - Phone
Your answer
Please provide a more detailed description of this Witness/Involved's involvement in the crash.
Your answer
Witness/Involved #3
Witness/Involved #3 - role
Witness/Involved #3 - Name
Your answer
Witness/Involved #3 - Address
Your answer
Witness/Involved #3 - Email
Your answer
Witness/Involved #3 - Phone
Your answer
Please provide a more detailed description of this Witness/Involved's involvement in the crash.
Your answer
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