Incident Report

Fill out as many fields as possible

An incident report must be submitted within 72-hours of an incident. Ride leaders must make sure that an incident report is filed for any incident that occurs on a ride they lead.

Fill out this form online. Print the completed form and mail it to SLOBC, P.O. Box 1585, San Luis Obispo, CA 93406.
For information email insurance@slobc.org.

Incident Date Time Reported by
Incident Information
Incident occurred on Club Ride:
Incident occurred Other:
Rider was wearing a helmet:  Yes  No Rider was on:  Single Bike  Tandem
Incident Location:  Highway  City Street  Country Road  Parking Lot  Other
Address/Cross Streets
Incident Description
Automobile Information
Driver's Name
Drivers License State
License Plate Number State
Police Officer
Officer's Name Affiliation
Injured Person Information
Name
Address
Phone
Emergency Contact Name Phone
 Club Member  Nonmember  Participant  Volunteer  Other
Injury Description
Witness Name Address Phone