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

Van # involved *

GIN *

Accident location *

Address, City, Zip Code

Accident type *

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 description of the collision. *

9. Photos of Damage

Please upload photos of damaged vehicle(s) or other objects and the surrounding area. 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