Your name (optional):
Your e-mail (required):
Date of accident:
Time of accident:
If dusk or dark, were you using some type of light or other illumination while riding? If so, please describe:
Road conditions (e.g., wet, dry, slippery, sandy, etc.):
Were you wearing a helmet? Y
Intersection or roadway/sidewalk/trail segment:
Number of people involved:
Number of vehicles involved:
Types of vehicles involved:
Were there any injuries?
If, yes, to whom (e.g., "bicyclist" or "pedestrian"):
Was there any damage to the vehicles or other property?
If yes, please describe:
Fault (if appropriate):
Hit an run (if motor vehicle involved)?
Was a police report filed?
Did you incur any costs as a result of the accident?
If so, approximately how much?