Roam Vehicle Report Form
Please complete the following questionnaire.
Name
*
First Name
Last Name
Email
*
Please use the same email address from your Roam Account
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Are you Reporting an Incident or Accident?
*
Incident (no one else was involved)
Accident (there were others involved)
Enter your vehicle information
Enter the Make and Model of your Vehicle (e.g. Honda Civic)
*
Make
Model
Enter Your License Plate Number
Enter the VIN and Plate Number of your Vehicle (located in your pink folder)
*
VIN Number of the Car
License Plate Number
Enter Incident Details
(For when no one else was involved)
Date and Time of Incident
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Is the Vehicle Currently Safe to Drive?
*
Describe the Incident (what happened) Include Relevant Details (weather conditions, injuries, speed, who was responsible, did police show up)
*
Describe the Extent of Damage on the Vehicle, Be as Detailed as Possible
*
Upload Photos of Your Vehicle Damages.
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Were others involved in the accident? If yes please provide us the information below.
*
Yes
No
Enter Accident Details
(For when others were involved)
Date and Time of Accident
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Is the Vehicle Currently Safe to Drive?
*
Describe the Accident (what happened) Include Relevant Details (weather conditions, injuries, speed, who was responsible, did police show up)
*
Describe the Extent of Damage on the Vehicle, Be as Detailed as Possible
*
Upload Photos of Your Vehicle Damage
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Do You Have a Police Report Number or Collision Reporting Centre Report Number?
*
Please Select
YES I have a Police Report Number
YES I have a Collision Reporting Centre Number
NO I do not have either
Enter Your Police Report Number
*
Upload a Photo of the Police Report (if available)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Enter Your Collision Reporting Centre Report Number
*
Upload a Photo of the Collision Reporting Centre Report (if available)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Other Party's Information
(Document all the information of the other party involved)
Other Party's Name
*
First Name
Last Name
Other Party's License Number
*
Upload Photos of Other Party's License (front and back)
*
Browse Files
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Choose a file
Cancel
of
Upload Photos of Other Party's Insurance
*
Browse Files
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Choose a file
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of
Other Party's Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Other Party's Phone Number
*
Please enter a valid phone number.
Make and Model of Other Party's Vehicle
*
Make
Model
License Plate Number of Other Party's Vehicle
*
Describe Damages on Other Party's Vehicle, Be as Details as Possible
*
Upload Photos of Damage to the Other Party's Vehicle
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Any witnesses Involved?
*
Yes
No
Witness Information
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Submit
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