Participant Injury Report Form
This form should be filled out and submitted when an incident or injury occurs that results in the following whether at a Practice or a Race:

*Referral or visit a medical facility
*Unable to complete or attend team practices, train or race
*Unable to attend school or work
*Unconsciousness or Potential brain injury

Information regarding Colorado League Insurance Overview and FAQ’s are HERE: https://docs.google.com/document/d/1rgbXDryEsrdRJgZo56ti2T4jFZp7rD1WT0zzLoS-mbc/edit?usp=sharing

IMPORTANT:
You must fill out, sign, this form: http://agadministrators.com/wp-content/uploads/2014/07/Participant-Accident-Claim-Form-Special-Risk.pdf.

List the "Team Name" - Colorado League as the the Special Risk Organization at the top.

The Head Coach/Team Director signs the bottom as the Special Risk Organization if it was an injury during a practice.

If it was an injury during a race email, it to kate@coloradomtb.org to sign before sending to the following email addresses:

Email the form to ALL of the following:
claims@agadm.com
info@UBInsurance.com
kate@coloradomtb.org

OR Send via FAX to ATTN: UBI Claims Department: info@UBInsurance.com or fax (801) 562-6388.

Please attend to this ASAP. Customer support for the insurance carrier 610.933.0800.

Here is a link with information on how to file a claim: http://agadministrators.com/services/how-to-file-a-claim/

The Accident Medical policy is excess over any other available insurance in regard to the injury. This policy will help cover reasonable and customary out of pocket medical expenses related to the injury such as deductibles and co-payments. The policy has an excess accident medical limit of $25,000 with a $250 deductible. The policy has a benefit period of 1 year from the date of the accident.

Email address *
First and Last Name of Person Filing Report *
Your answer
Email Address of Person Filing Report *
Your answer
Phone of Person Submitting Report *
Your answer
Role of Person Submitting Report (i.e. Coach, Volunteer, Parent) *
Your answer
Date and Time of Incident *
Your answer
Name of Club/Team *
Your answer
Injured Person *
Name of Injured Person *
Your answer
Email of person legally responsible for injured *
VERY IMPORTANT to include the primary Parent's email if a student is injured
Your answer
Cell Phone of Legally responsible *
Parent's phone if student is injured
Your answer
Street Address *
Your answer
City, Sate & Zip Code *
Your answer
Age of Injured Person *
Your answer
Sex of Injured Person *
During which activity did the injury occur? *
If other, please explain.
Your answer
Affected Body Part *
Primary injury or injuries
Required
Describe the Injury *
Your answer
Briefly Describe the Circumstances that caused the injury. *
Your answer
On Site Care Given By *
Choose all that apply
Care Provided on Site *
Choose all that apply
Parent / Guardian Notified *
Did the injury result in any of the following? *
Taken to Doctor / Hospital? *
If yes, add location
Your answer
Name, Phone Number, Email of Two (2) Witnesses
Your answer
Name and Title of Person in Charge at Time of Incident (Kate Rau for Race Incidents, Coach for Practices) *
Your answer
A copy of your responses will be emailed to the address you provided.
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This form was created inside of Colorado High School Cycling League. Report Abuse - Terms of Service - Additional Terms