Customer Incident Report
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1CUSTOMER INCIDENT REPORT
CLAIM
COLLISION
THEFT OR PERSONAL INJURY
THEFT OF PART OF CAR
BODILY INJURY
TYPE
NAME:
HOME
(
)
-
PHONE:
ADDRESS:
WORK
Ext.
(
)
-
PHONE:
CITY:
STATE:
ZIP CODE:
LOCATION NO.:
LOCATION NAME:
LOCATION
ADDRESS:
DATE OF INCIDENT:
TIME OF INCIDENT:
LOCATION
CITY ST ZIP:
TICKET NO#
TICKET COLOR:
DATE ENTERED:
TIME ENTERED:
DATE EXITED:
TIME EXITED:
TYPE OF
COMBINATION OF SELF & VALET
SELF PARK
VALET/ATTENDED
FACILITY
NAME OF
NAME OF
IF VALET OR ATTENDANT
VALET IN:
VALET OUT:
PARKED VEHICLE
OWNER OF
VEHICLE MAKE:
VEHICLE MODEL:
AUTO:
OWNERS
VEHICLE YEAR:
VEHICLE COLOR:
ADDRESS:
CITY:
STATE:
ZIP:
LICENSE PLATE #:
ESTIMATE AMT. OF LOSS:
Y
N
WHEN INCIDENT OCCURRED HAD
Y
N
HAD CAR BEEN RETURNED TO
CAR BEEN TURNED OVER TO US?
CLAIMANT?
IF NOT REPORTED, WHY?
WAS CLAIM REPORTED PRIOR TO VEHICLE
Y
N
LEAVING THE FACILITY?
List
Damages-
Attach photo
if available
(PRINT)
Customer
Manager’s
Phone: __________________________
Signature: ________________________________________ Date: _________________
Name:
___________________________________
Date: ______________________
WHERE WAS VEHICLE
FRONT
Y
N
REAR
Y
N
TOP
Y
N
DRIVE
Y
N
PASS
Y
N
DAMAGED?
SIDE
SIDE
WERE STOLEN ITEMS
Y
N
IF NOT, WHERE WERE
FRONT
Y
N
BACK
Y
N
TRUNK
Y
N
ATTACHED TO AUTO?
ITEMS STOLEN FROM?
SEAT
SEAT
WAS A POLICE
Y
N
DATE OF REPORT
PRECINCT
REPORT FILED?
WITNESS
NAME:
ADDRESS:
CITY, STATE, ZIP
PHONE:
INFO
DISPOSITION:
SR MGR SIGNATURE:
SR MGR PHONE:
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Parent category: Business