PCI - ATTENDANT'S AUTO INCIDENT REPORT

ATTENDANT'S AUTO INCIDENT REPORT
Date

MonthDayYear
Date
PCI Location*
Report Type
OTHER EXPLAIN:
Claim #
Claimant's Name

First NameLast Name
Claim Investigated By

First NameLast Name
Did any employee see the accident or theft occur?
If yes, give name of the witness

First NameLast Name
Witness details
Was a PCI Employee involved?
If yes, give their name(s)

First NameLast Name
First NameLast Name
Was damage caused by the attendant's carelessness?
Was damage caused by mechanical failure or breakdown?
Other (Specify)
1. Did the customer park his/her own car?
2. Did the customer lock car and retain the keys?
3. Was the car parked on the premises before Attendant opened?
4.Was the car parked on the premises when Attendant closed?
5. Did customer leave the premises before reporting the damage?
6. How long before he/she returned before reporting the damage?
7. Was the damage fresh?
8.Were there any paint particles on the damaged area?
9.Was there any dust or road film on the damaged area?
10, Was there any paint particles or parts on the ground where the car was parked?
Other pertinent information
ATTENDANT'S SIGNATURE *
ATTENDANT'S PHONE NUMBER*
Please enter a valid phone number.Format: (000) 000-0000.
ATTENDANT'S EMAIL*
example@example.com
ATTENDANT'S NAME*

First NameLast Name
Should be Empty: