Incident Report
Complete if damage was caused to your vehicle
Full Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid Canadian phone number.
Your/Roam Vehicle
*
Include Year, Make & Model
Licence Plate Number
*
Incident Information
Please provide detailed information pertaining to the incident which caused damage to the vehicle.
When did the incident occur?
*
-
Month
-
Day
Year
Date
Upload pictures of the damage
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
In as much detail as possible, please explain the situation.
*
What happened? Include details such as weather conditions, road/traffic conditions, speed you were traveling at time of incident, who was responsible, was police involved, etc.
If another party was involved, enter their information.
Other party's full name
First Name
Last Name
Upload photo of their insurance
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Other party's information (if no photo of insurance is available)
Include email, phone number, & insurance information
If there were any witnesses, provide their names and contact information
Name & phone number
Should be Empty: