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
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 Georgia Cycling Association Insurance Policy can be accessed here.
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.
The Georgia Cycling Association 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.
Georgia Cycling Association members (including coaches and students) are eligible to submit claims that are over and above what their own medical insurance covers, up to a limit of $25,000, with a $500 deductible.
By completing the form below, your information will be electronically sent to representatives from the Georgia Cycling Association, Sports Underwriters, Players Health, and NAHGA Claim Services.