SLOBC Incident Report Form

Please fill out as many fields as possible in the form below

Our insurance carrier requires that we file an incident report with them within 72-hours of an incident on one of our rides. We ask that ride leaders ensure that an incident report is filed for any incident that occurs on a ride they are leading. You can fill out this form, online, print the completed form, and mail it to Bruce Collier, 1203 Pismo St, SLO 93401. If you have any questions, contact Bruce (543-9514) or Frank Mullin (518-9003).

Incident Date TimeReported by
Incident Information
Incident occurred on club ride Other
Rider was wearing a helmetYes NoRider on Single BikeTandem

Incident Location: HighwayCity StreetCountry RoadParking Lot Other
Address/Cross Streets

If automobile involved, License Number State
Driver's Name   License  State
Description of Incident
If police present, Officer's Name  Affiliation
Injured Person Information
Name Bib Number 
Address   Phone
City  State  Zip
Emergency Contact Name  Phone
Club Member NonmemberParticipant Volunteer Other
Description of Injuries
Witness Name AddressPhone