Collision Report

Please complete and submit to Pierce Transit Vanpool 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. Vanpool Driver Information

Name *

First Name MI Last Name

Phone Number *

Please enter a valid phone number.

Email

example@example.com

*

Primary driver Backup driver Other (specify)

Home Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

2. Other Party Information

How many other vehicles were involved? *

0 1 2 3 4+

STOP

If 4 or more other vehicles were involved, please contact our office at 253.581.8000 (press 3, then 2). We will provide you with instructions for submitting a collision report for an accident involving 4 or more other vehicles.

Vehicle 1

Upload photo of vehicle 1 Information Exchange Card (Blue) completed by other driver here:

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.

Vehicle 1 Driver Name *

First Name MI Last Name

Vehicle 1 Driver Phone Number *

Please enter a valid phone number.

Vehicle 1 Driver Email

example@example.com

Vehicle 1 Driver Home Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Upload photo of vehicle 1 driver license here:

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.

Vehicle 1 Driver License # *

Vehicle 1 Driver License State *

Vehicle 1 Year *

Vehicle 1 Make/Model *

Vehicle 1 Color *

Vehicle 1 VIN #

Vehicle 1 License Plate # *

Vehicle 1 License Plate State *

Upload photo of Vehicle 1 insurance card here:

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.

Vehicle 1 Insurance Company Name *

Note if no insurance

Vehicle 1 Policy # *

Vehicle 1 Insurance Company Phone Number *

Please enter a valid phone number.

Is the Vehicle 1 driver the registered owner? *

Yes No

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

First Name MI Last Name

Vehicle 1 Registered Owner's Phone Number *

Please enter a valid phone number.

Vehicle 1 Registered Owner's Email

example@example.com

Vehicle 1 Registered Owner's Home Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Vehicle 2

Upload photo of vehicle 2 Information Exchange Card (Blue) completed by other driver here:

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.

Vehicle 2 Driver Name *

First Name MI Last Name

Vehicle 2 Driver Phone Number *

Please enter a valid phone number.

Vehicle 2 Driver Email

example@example.com

Vehicle 2 Driver Home Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Upload photo of vehicle 2 driver license here:

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.

Vehicle 2 Driver License # *

Vehicle 2 Driver License State *

Vehicle 2 Year *

Vehicle 2 Make/Model *

Vehicle 2 Color *

Vehicle 2 VIN #

Vehicle 2 License Plate # *

Vehicle 2 License Plate State *

Upload photo of Vehicle 2 insurance card here:

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.

Vehicle 2 Insurance Company Name *

Note if no insurance

Vehicle 2 Policy # *

Vehicle 2 Insurance Company Phone Number *

Please enter a valid phone number.

Is the Vehicle 2 driver the registered owner? *

Yes No

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

First Name MI Last Name

Vehicle 2 Registered Owner's Phone Number *

Please enter a valid phone number.

Vehicle 2 Registered Owner's Email

example@example.com

Vehicle 2 Registered Owner's Home Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Vehicle 3

Upload photo of vehicle 3 Information Exchange Card (Blue) completed by other driver here:

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.

Vehicle 3 Driver Name *

First Name MI Last Name

Vehicle 3 Driver Phone Number *

Please enter a valid phone number.

Vehicle 3 Driver Email

example@example.com

Vehicle 3 Driver Home Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Upload photo of vehicle 3 driver license here:

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.

Vehicle 3 Driver License # *

Vehicle 3 Driver License State *

Vehicle 3 Vehicle Year *

Vehicle 3 Make/Model *

Vehicle 3 Color *

Vehicle 3 VIN #

Vehicle 3 License Plate # *

Vehicle 3 License Plate State *

Upload photo of Vehicle 3 insurance card here:

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.

Vehicle 3 Insurance Company Name *

Note if no insurance

Vehicle 3 Policy # *

Vehicle 3 Insurance Company Phone Number *

Please enter a valid phone number.

Is the Vehicle 3 driver the registered owner? *

Yes No

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

First Name MI Last Name

Vehicle 3 Registered Owner's Phone Number *

Please enter a valid phone number.

Vehicle 3 Registered Owner's Email

example@example.com

Vehicle 3 Registered Owner's Home Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

3. Vanpool Passengers & Witnesses

Were there any passengers or witnesses? *

Yes No

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 Vanpool@PierceTransit.org.

4. Injury Information

Were there any injuries? *

Yes No

Please describe: *

5. Accident Details

Accident Date and Time *

Date

Hour Minutes AM/PM Option

Vehicle # involved *

GIN *

Accident location *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Accident type *

Was the vanpool vehicle towed? *

Yes No

Were any other vehicles towed? *

Yes No

Please list which vehicles were towed. *

Did the police respond to the scene of the accident? *

Yes No

Police Case #

Which agency provided the case #

Officer's Name

Officer's Badge #

Officer's Phone Number

Were any citations issued? *

Yes No

Who received the citation and what were they cited for?

6. Weather/Road Conditions

Please select the type of weather *

Please select the type of light conditions *

Please select the road conditions *

7. Vehicle Travel/Traffic Control

Vanpool Vehicle

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 traveling direction. *

Please select the vehicle movement. *

Please select the type of traffic control. *

Vehicle 1

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

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

What speed was Vehicle 1 traveling at? *

(e.g. 35 mph)

Vehicle 1: What was the posted speed limit? *

(e.g. 25 mph)

Vehicle 1: Please select the traveling direction. *

Vehicle 1: Please select the vehicle movement. *

Vehicle 1: Please select the type of traffic control. *

Vehicle 2

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

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

What speed was Vehicle 2 traveling at? *

(e.g. 35 mph)

Vehicle 2: What was the posted speed limit? *

(e.g. 25 mph)

Vehicle 2: Please select the traveling direction. *

Vehicle 2: Please select the vehicle movement. *

Vehicle 2: Please select the type of traffic control. *

Vehicle 3

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

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

What speed was Vehicle 3 traveling at? *

(e.g. 35 mph)

Vehicle 3: What was the posted speed limit? *

(e.g. 25 mph)

Vehicle 3: Please select the traveling direction. *

Vehicle 3: Please select the vehicle movement. *

Vehicle 3: Please select the type of traffic control. *

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

9. Photos of Damage

Please upload photos of damaged all damaged vehicles or other objects and the surrounding area. Photos of the vanpool vehicle and any other vehicles involved in collision should be provided. Photos should include the following:

All 4 sides of the vanpool 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 Vanpool@PierceTransit.org.

Please provide your name: *

Date