DRS Windshield Loss Notice

• Employee Name

• Office location

• Company Phone Number

• Scheduled Days Off

• Windshields are usually replace at your home, on your day off, so that you do not have to swap vans. If you need to have the repair done at the office, it will require you to temporarily swap vans so yours will be available for repair. To arrange a van swap, see your FSM.

• What is the address where the windshield replacement will take place?

• Date this report was conducted on

  Date

• Prepared by

• Location
  Address

• This form when completed should be emailed to claims@drsinstall.com

Our vehicle information

• Company vehicle number

• Year of vehicle

• Make and Model (Chevy Express van, etc.)

• VIN#

• License Plate Number

• Mileage

• Is the vehicle drivable?

  Yes

  No

  N/A

• Where was it taken?

• Phone number of where it was taken

Incident Information

• Describe the Damage (be specific and detailed)

• Take a photo of the damage

  Media

• What was the date and time of the incident?

  Date

• What were you doing at the time of the incident?

Conditions

• Was the weather Clear, Foggy, Raining, or Other?

• Was the traffic Heavy, Moderate, or Light?

• Was the road surface paved or non-paved?

• I attest that the information I have provided is true to the best of my knowledge and upon becoming aware of any changes, I will immediately contact my supervisor and HR.

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