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Incident & Accident Report Form

Incident & Accident Report Form

If you have been involved in an accident while participating in an event or training as part of your Cycling Ireland membership please fill in the form below. Please include full details and these will be automatically forwarded to Cycling Ireland’s offices and to O’Driscoll O’Neil. In order to make a claim under the policy you must complete a full claim form which will be issued to you.

Members Name * Members Club (if applicable) Members Licence Number * Members Address * Members Phone Number * Members Email Address * Contact details of person completing form (if different to those of member) Date of Incident * Name of event at which incident occurred and contact details of promoting club / organiser (if applicable) Describe weather and road / route conditions * Relevant details of third parties / witnesses (names, contact details, registration numbers etc.) Full details of Garda / PSNI presence (if applicable) Describe the incident and nature of injuries / damage * If hospitalisation was required please give full details This form has been submitted by *

I confirm that the above details are, to the best of my knowledge, true *

Claims can only be made by those holding a current Cycling Ireland licence as at the date of the incident.