Automobile Damage

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Please complete all fields below and be as specific as possible

Report prepared by*

Position*

Department*

Report Completed*

Date of Incident*

Time of Incident*

Building Name*

Building Address*

#, Street, City, Zip

Is the Garage Attended?*

Driver #1 Name*

Driver #1 Address*

#, Street, City, Zip

Driver #2 Name

Driver #2 Address

#, Street, City, Zip

Registrant #1 Address*

If different from above address

Auto Carrier #1*

Policy Number #1*

Registrant #2 Address

If different from above address

Auto Carrier #2

Policy Number #2

Type of Vehicle

Model*

License Plate #*

Year*

Vehicle Damage*

Describe in detail what was reported*

Were any injuries reported?*

Injured #1 Name*

Injured #1 Address*

Injured #2 Name

Injured #2 Address

Give name and position of employee who inspected the damage*

Visible Handicaps*

Did Police respond

Precinct #

Badge#

Complaint #

Aided #

Videos or Photos/Taken*

If yes, how many?

File

Max. file size: 50 MB.

Photo(s)

Drop files here or

Max. file size: 50 MB.

Cameras*

If yes, what locations?

Was a Service Request sent to review and archive?*

Requested by*

Comments*