Accident Form

All accident reports must be submitted to The Rideshare Company within 48 hours. Be sure to complete the entire form below. For accidents involving more than two Rideshare vehicles, submit additional accident reports.

Alternatively you can download a copy of the form and return it to us.

Download Form 

---

Please fill in the form below and use the comments box for comments and questions: (* denotes required fields)

First Name * Middle Initial Last Name *
Email *	Phone *
Employer *
Plate # *	Today's Date *
Date of Accident *	Time of Accident *
Number of Vehicles Involved *	Number of Injuries * Number of Fatalities *
Was there damage to property other than vehicles? *
Yes	No
Location of Accident (City or Town)	Street Name or Route #
Was there police action? *
Yes No State Police Other
Officer Name & Badge #
Was a traffic warning/summons issued by police? *
Warning Summons None Not Sure
To Whom?
Nature of Violation	Case #

Vehicles Involved

Vehicle #1 (Rideshare Vehicle)

First Name * Middle Initial Last Name *
Residence Address *
City *	State * Zip *
Date of Birth *	Sex Male Female
Home/Cell Telephone *	Email
Work Telephone	Extension
Driver's License # * Issued by (State) * Expiration Date *
Vehicle Year Make Model
VIN # *
Plate # *	Group #

Vehicle #2 (Other Driver Involved)

First Name Middle Initial Last Name
Residence Address
City	State Zip
Date of Birth	Sex Male Female
Home/Cell Telephone	Email
Work Telephone	Extension
Driver's License # Issued by (State) Expiration Date
Vehicle Year Make Model
VIN #
Plate #	Group #

Conditions

Rideshare Vehicle Speed (mph) *	Vehicle #2 (mph)
Weather & Light Conditions (Describe: snow, fog, daylight, etc.) *
Road Conditions (Describe: wet, dry, unpaved, etc.) *

Explain What Happened *

Describe all events before, during and after the incident.

Damage to Rideshare Vehicle *

Damage to Other Vehicle and/or Property *

Property Owner Name

Address

Witnesses

Include names, address, and telephone numbers

Rideshare Vehicle

Name *	Telephone *
Address *

Add a witness

Others

Name	Telephone
Address

Add a Witness

Injuries

Rideshare Vehicle

Name	Age
Nature of Injury

Add an Injury

Vehicle #2

Name	Age
Nature of Injury

Add an Injury

Name and addresses of injured pedestrians or bicyclists:

Driver Signature *

Date *

---

A copy of the accident report will be emailed to you once you submit the form.