Insurance Claim Worksheet

Insurance Claim Worksheet

Initiation Date

Name of Insured Member



Phone Number

Email Address

Copy of Drivers Licence

Date of Occurence

Location of Occurrence

Name of Employer

Address of Employer

Does the member have insurance through their employer?

Does the member have extended insurance through their partner's benefits?

Does the member have travel insurance?

Is the member eligible for provincial insurance?

Please confirm the date of your first visit to your doctor or emergency room.

Please provide your diagnosis

When did the member return to cycling?

Did your accident involve a motor vehicle?

Did the operator of the motor vehicle stay at the scene?

If you spoke with the drive of the motor vehicle, did that person share their insurance information with you? If so, please enter it here.

Please share anything about the driver or the car involved in your accident?

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Bicycle Nova Scotia