Colorado League Injury Report Form
This form should be filled out immediately when an incident or injury occurs that results in the following 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
* More than minor first aid is performed

This report form is required even if you do not intend to file a claim.

This ensures that if an injury results in further care beyond the initial assessment the report is complete to accompany a potential future claim.

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

IMPORTANT:
Written notice of incidents must be submitted within 30 days after the incident. Treatment must begin 30 days from the date of the injury. Benefits are payable 52 weeks from the date of an injury.

Upon signing the Liability Waiver, participants agreed to be fully responsible for their own medical expenses. The League understands that accidents can happen, and it is not the fault of anyone. The League has purchased an excess accident medical policy that can help pay for eligible medical expenses that are in excess of expenses payable by any other available insurance in regard to the injury.

Colorado League participants (including coaches, students, staff and volunteers) are eligible to submit claims that are over and above what your own medical insurance covers, up to a limit of $25,000, with a $1,000 deductible.

IMPORTANT:
If you intend to file an accident medical claim with the League’s insurance, you must:

1. Fill out and sign this Participant Accident Claim Form:

https://agadministrators.com/uploads/files/Participant-Accident-Claim-Form-Special-Risk.pdf

Claim Form Instructions:

* List the "Team Name" - Colorado High School Cycling League as 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:

Christopher Pesigan: chris@playershealth.com
Kate Rau: kate@coloradomtb.org

Written notice of incidents must be submitted within 30 days after the incident.

2. Provide your healthcare provider (the doctor’s office, ER, etc.) with the following insurance information, to be billed as your secondary insurance provider.

A-G Administrators
PO Box 979
Valley Forge, PA 19482
Phone: 610-933-0800
Fax: 610-935-2860

The carrier will need the following information to respond to your claim:

* Certificate Holder: Colorado High School Cycling League
* Certificate Number: SRPO-162253-01
* Copy of primary insurance explanation of benefits
* Copies of itemized medical bills
Email address *
First Name of Person Filing Report *
Last Name of Person Filing Report *
Email Address of Person Filing Report *
Phone of Person Submitting Report *
Role of Person Submitting Report (i.e. Coach, Volunteer, Parent) *
Date and Time of Incident *
Name of Club/Team *
Trail/Race and location where Injury occurred *
Land Manager/Owner of property where injury occurred *
Injured Person *
First Name of Injured Person *
Last Name of Injured Person *
First Name of Person Legally responsible for Injured Person *
Last Name of Person Legally responsible for Injured Person *
Email of person legally responsible for injured *
VERY IMPORTANT to include the primary Parent's email if a student is injured
Cell Phone of Legally responsible *
Parent's phone if student is injured
Street Address *
City, Sate & Zip Code *
Age of Injured Person *
Sex of Injured Person *
During which activity did the injury occur? *
If other, please explain.
Affected Body Part *
Primary injury or injuries
Required
Describe the Injury *
Briefly Describe the Circumstances that caused the injury. *
On Site Care Given By *
Choose all that apply.
Required
Care Provided on Site *
Choose all that apply
Required
Parent / Guardian Notified *
Did the injury result in any of the following? *
Required
Taken to Doctor / Hospital? *
If yes, add location
Name, Phone Number, Email, Address of Two (2) Witnesses
Name and Title of Person in Charge at Time of Incident (Kate Rau for Race Incidents, Coach for Practices) *
Kate Rau for Race Incidents, Associated Coach for Practices
A copy of your responses will be emailed to the address you provided.
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