Title Page
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Claim Number
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Conducted on
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Prepared by
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First thing you do is make sure everyone involved is ok and safe with no injuries. If anyone is injured seek medical assistance immediately and if it is a team member complete a first report of incident injury form. Next is to gather Claimant Contact Information
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Time incident reported (24H format)
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Claimant Name
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Witness Name
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Witness Phone
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Witness Statement
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Witness Signature
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Were Police called?
Police information
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Officers Business Card Photo
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Officers Name
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Officers Phone Number
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Officers Report #
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Claimant Email
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Claimant Mailing Address
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Claimant Phone Number
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Vehicle 1 Make
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Vehicle 1 Model
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Vehicle 1 Color
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Vehicle 1 Year
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Vehicle VIN
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Vehicle VIN #
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Vehicle License Plate
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Service Point where reported
- Charlton
- Gonda
- Saint Marys
- Emergency Department
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Vehicle Damage Photo 1
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Vehicle Damage Photo 2
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That will conclude all the information needed from the claimant. You should now ensure they are able to safely depart the facility with comfortable accommodations and continue the remaining investigation after they have left the area.
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Type of Claim
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Was incident reported prior to leaving?
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Was damage noted on damage Assesment?
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Damage Assesment Ticket Vehicle Drawing side
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Valet Ticket Number
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Valet Storage Stall # or Location
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When incident occurred had car been turned over to us?
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Valet that Parked Vehicle
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Valet that Parked Vehicle phone number
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Valet that Retrieved vehicle
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Valet that Retrieved vehicle phone number
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Summary of incident
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Were there any witnesses
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Signature of Supervisor completing report
