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

Driver Role

Other (specify)

Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

2. Other Party Information

How many vehicles other than the Pierce Transit Rideshare vehicle were involved?

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.

Is the Other Vehicle 1 driver the registered owner?

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.

Is the Other Vehicle 2 driver the registered owner?

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.

Is the Other Vehicle 3 driver the registered owner?

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

Were there any passengers or witnesses?

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

Were there any injuries?

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

Was the Rideshare vehicle towed?

Were any other vehicles towed?

Please list which vehicles were towed.

Did the police respond to the scene of the accident?

Police Case #

Which agency provided the case #

Officer's Name

Officer's Badge #

Officer's Phone Number

Were any citations issued?

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

WSDOT Grant Funded Vehicle?