Collision Report

Please complete and submit to Pierce Transit Rideshare within 24 hours of collision.

If there is significant damage to the vehicle (likely to exceed $1,000), law enforcement was not at the scene, the other party was uninsured, or injuries were sustained, you must complete a Washington State Collision Report in addition to this Pierce Transit Collison Report.

1. Rideshare Driver Information

Name*

First NameMILast Name

Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Primary driverBackup driverOther (specify)

Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

2. Other Party Information

Other Vehicle 1

Upload a photo of the Other Vehicle 1 Information Exchange Card (Blue) completed by the other driver:

Attachments must be no larger than 5 MB. If file size is too large or photos do not upload properly, please send to Vanpool@PierceTransit.org.

Other Vehicle 1 Driver Name*

First NameMILast Name

Other Vehicle 1 Driver Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Other Vehicle 1 Driver Email

example@example.com

Other Vehicle 1 Driver Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Upload a photo of a driver license for Other Vehicle 1 driver:

Attachments must be no larger than 5 MB. If file size is too large or photos do not upload properly, please send to Rideshare@PierceTransit.org.

Other Vehicle 1 Driver License #*

Other Vehicle 1 Driver License State*

Other Vehicle 1 Year*

Other Vehicle 1 Make/Model*

Other Vehicle 1 Color*

Other Vehicle 1 VIN #

Other Vehicle 1 License Plate #*

Other Vehicle 1 License Plate State*

Upload a photo of the insurance card for Other Vehicle 1 driver:

Attachments must be no larger than 5 MB. If file size is too large or photos do not upload properly, please send to Rideshare@PierceTransit.org.

Other Vehicle 1 Insurance Company Name*

Note if no insurance

Other Vehicle 1 Policy #*

Other Vehicle 1 Insurance Company Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

YesNo

Other Vehicle 1 Registered Owner's Name (if not driver)*

First NameMILast Name

Other Vehicle 1 Registered Owner's Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Other Vehicle 1 Registered Owner's Email

example@example.com

Other Vehicle 1 Registered Owner's Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Other Vehicle 2

Upload a photo of Other Vehicle 2 Information Exchange Card (Blue) completed by the other driver:

Attachments must be no larger than 5 MB. If file size is too large or photos do not upload properly, please send to Rideshare@PierceTransit.org.

Other Vehicle 2 Driver Name*

First NameMILast Name

Other Vehicle 2 Driver Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Other Vehicle 2 Driver Email

example@example.com

Other Vehicle 2 Driver Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Upload a photo of a driver license for Other Vehicle 2 driver:

Attachments must be no larger than 5 MB. If file size is too large or photos do not upload properly, please send to Rideshare@PierceTransit.org.

Other Vehicle 2 Driver License #*

Other Vehicle 2 Driver License State*

Other Vehicle 2 Year*

Other Vehicle 2 Make/Model*

Other Vehicle 2 Color*

Other Vehicle 2 VIN #

Other Vehicle 2 License Plate #*

Other Vehicle 2 License Plate State*

Upload a photo of the insurance card for Other Vehicle 2 driver:

Attachments must be no larger than 5 MB. If file size is too large or photos do not upload properly, please send to Vanpool@PierceTransit.org.

Other Vehicle 2 Insurance Company Name*

Note if no insurance

Other Vehicle 2 Policy #*

Other Vehicle 2 Insurance Company Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

YesNo

Other Vehicle 2 Registered Owner's Name (if not driver)*

First NameMILast Name

Other Vehicle 2 Registered Owner's Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Other Vehicle 2 Registered Owner's Email

example@example.com

Other Vehicle 2 Registered Owner's Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Other Vehicle 3

Upload a photo of Other Vehicle 3 Information Exchange Card (Blue) completed by the other driver:

Attachments must be no larger than 5 MB. If file size is too large or photos do not upload properly, please send to Rideshare@PierceTransit.org.

Other Vehicle 3 Driver Name*

First NameMILast Name

Other Vehicle 3 Driver Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Other Vehicle 3 Driver Email

example@example.com

Other Vehicle 3 Driver Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Upload a photo of a driver license for Other Vehicle 3 driver:

Attachments must be no larger than 5 MB. If file size is too large or photos do not upload properly, please send to Rideshare@PierceTransit.org.

Other Vehicle 3 Driver License #*

Other Vehicle 3 Driver License State*

Other Vehicle 3 Vehicle Year*

Other Vehicle 3 Make/Model*

Other Vehicle 3 Color*

Other Vehicle 3 VIN #

Other Vehicle 3 License Plate #*

Other Vehicle 3 License Plate State*

Upload a photo of the insurance card for Other Vehicle 3 driver:

Attachments must be no larger than 5 MB. If file size is too large or photos do not upload properly, please send to Rideshare@PierceTransit.org.

Other Vehicle 3 Insurance Company Name*

Note if no insurance

Other Vehicle 3 Policy #*

Other Vehicle 3 Insurance Company Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

YesNo

Other Vehicle 3 Registered Owner's Name (if not driver)*

First NameMILast Name

Other Vehicle 3 Registered Owner's Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Other Vehicle 3 Registered Owner's Email

example@example.com

Other Vehicle 3 Registered Owner's Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

3. Rideshare Passengers & Witnesses

YesNo

Please provide names and contact information for passengers and witnesses. This information should be provided on any Courtesy Card(s) that were completed at the scene.*

Upload photos of completed Courtesy Cards here:

Attachments must be no larger than 5 MB. If file size is too large or photos do not upload properly, please send to Rideshare@PierceTransit.org.

4. Injury Information

YesNo

Please describe:*

5. Accident Details

Accident Date and Time*

Date

Hour MinutesAM/PM Option

What is the vehicle number of the Rideshare vehicle involved in the collision?*

This is the 4-digit number listed on the side of the Rideshare vehicle.

Group ID Number (GIN)*

This is your Rideshare group's 4-digit ID number.

Accident location*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Accident type*

YesNo

Please list which vehicles were towed.*

YesNo

Police Case #

Which agency provided the case #

Officer's Name

Officer's Badge #

Officer's Phone Number

YesNo

Who received the citation and what were they cited for?

6. Weather/Road Conditions

Please select the weather conditions*

Please select the light conditions*

Please select the road conditions*

Please select the road type*

7. Vehicle Travel/Traffic Control

Please provide the name of the roadway you were traveling on.*

(e.g. Rainier Ave, 72nd Street, I-5)

What speed were you traveling at?*

(e.g. 35 mph)

What was the posted speed limit?*

(e.g. 25 mph)

Please select the direction of travel of the Rideshare vehicle.*

Please select the vehicle movement of the Rideshare vehicle.*

Please select the type of traffic control:*

Other Vehicle 1

Please provide the name of the roadway Other Vehicle 1 was traveling on:*

(e.g. Rainier Ave, 72nd Street, I-5)

What speed was Other Vehicle 1 traveling at?*

(e.g. 35 mph)

What was the posted speed limit for Other Vehicle 1?*

(e.g. 25 mph)

Please select the direction of travel of Other Vehicle 1:*

Please select the vehicle movement of Other Vehicle 1:*

Please select the type of traffic control for Other Vehicle 1:*

Other Vehicle 2

Please provide the name of the roadway Other Vehicle 2 was traveling on:*

(e.g. Rainier Ave, 72nd Street, I-5)

What speed was Other Vehicle 2 traveling at?*

(e.g. 35 mph)

What was the posted speed limit for Other Vehicle 2?*

(e.g. 25 mph)

Please select the direction of travel of Other Vehicle 2:*

Please select the vehicle movement of Other Vehicle 2:*

Please select the type of traffic control for Other Vehicle 2:*

Other Vehicle 3

Please provide the name of the roadway Other Vehicle 3 was traveling on:*

(e.g. Rainier Ave, 72nd Street, I-5)

What speed was Other Vehicle 3 traveling at?*

(e.g. 35 mph)

What was the posted speed limit for Other Vehicle 3?*

(e.g. 25 mph)

Please select the direction of travel of Other Vehicle 3:*

Please select the vehicle movement of Other Vehicle 3:*

Please select the type of traffic control for Other Vehicle 3:*

8. Please provide a DETAILED description of the collision.*

9. Photos of Damage

Please upload photos of the Rideshare vehicle, any other vehicles involved in the collision, and any damaged property. Photos should include the following:

All 4 sides of the Rideshare vehicle
All 4 sides of the surrounding area (turn your back to the vehicle and take a photo from each side)
All 4 sides of any damaged vehicles
Any damage to objects or property

Upload photos of damage and the surrounding area here:*

Attachments must be no larger than 5 MB. If file size is too large or photos do not upload properly, please send to Rideshare@PierceTransit.org.

Please provide your name:*

Date

FOR USE BY PIERCE TRANSIT ONLY

YesNo