Collision Courtesy Card
In the event of a collision, please have any Rideshare passengers, witnesses or bystanders provide the requested information in the fields below. If you have any questions, please contact Pierce Transit Risk Management at 253.983.3794.
I am a:
Please Select
Rideshare Passenger
Witness
Bystander
Name
*
First Name
MI
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Email
example@example.com
Accident Information
Date of Accident
*
-
Month
-
Day
Year
Date
Time of Day
*
Hour Minutes
AM
PM
AM/PM Option
Vehicle #
GIN #
Location
*
72nd Ave S, Rainier Ave, HWY 512, I-5
Did you see the accident?
*
Yes
No
Please describe:
Did anyone appear to be injured?
*
Yes
No
Please describe:
Were you a passenger on the Pierce Transit Rideshare vehicle?
*
Yes
No
Where were you seated in the Rideshare vehicle?
(e.g. driver, front passenger, second row, etc.)
The above statement is true and correct to the best of my knowledge.
Signature
*
Submit
Date
-
Month
-
Day
Year
Date
Should be Empty: