Rider SOS Accident Fund Help Request
If you or a loved one were involved
in a motorcycle crash, please fill out
the attached form, and someone
will be in touch within 48 hours. All
requests must be submitted in
writing, and then a member of our
community will reach out to you for
additional information. All fields
with an asterisk * are required.
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Email *
Today's Date *
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Name of Person Filling Out Form & Relationship *
Your Phone Number *
Your Email Address *
Rider Legal Name *
Rider Nickname & Club Affiliation if Applicable
Rider Phone Number
Rider Email Address
Rider Facebook & Instagram name(s) *
Rider Home Address *
Next of kin name and phone number if accident was fatal
Date of Accident *
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Responding Law Enforcement Agency & Report Number *
Where was the accident? Include major cross streets and city/state. *
What happened in the accident? Give as complete details as possible. *
Description of Injuries Sustained and Any indication of recovery time frame. *
Rider Current Condition *
If still hospitalized, what hospital and room number?
Was there a passenger? *
Passenger Name
Passenger Phone
Passenger Condition
Type of Assistance Requested (Please check all that apply): *
Required
Would you like to be contacted by an experienced motorcycle accident attorney? *
Is the Rider a member of any of the following groups? *
Required
Have you applied or received assistance from any other nonprofit group related to this accident? If yes, please list where you have applied.

If you have created a crowd sourcing fundraiser including go fund me or similar, please include that link here.   *
Please add any additional details here that you feel are relative to the riders needs. *
If it is determined that you were under the influence of alcohol or drugs at the time of the accident, the fee-free fundraising portion of the help request will be denied. The Rider SOS Accident Fund advocates for safe, sober, and responsible riding. The only exception is if the accident resulted in a fatality, Rider SOS will still assist the family. *
What to expect
Once you fill out this online application, one of our volunteers will contact you. They will review the facts of the accident, your
financial and medical needs, and help determine what your immediate needs are. The volunteer will report back to our
board members and the board will determine how we can help based
on multiple factors, including the funds we have available. Once a
determination is made, a board member will contact you to discuss
how we can help.

In the meantime, please text 3 - 5 photos of the Rider to 702-412-8792. These photos should NOT be accident photos.  We want images to use to create a fundraiser that show the Rider before the accident.  These photos may include other immediate family members or friends only with their permission. *
Riders Birthdate *
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A copy of your responses will be emailed to the address you provided.
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