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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? *
Location of Accident (City or Town)
Street Name or Route #
Was there police action? *
Officer Name & Badge #
Was a traffic warning/summons issued by police? *
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
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
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 *

Others

Name
Telephone
Address

Injuries

Rideshare Vehicle

Name
Age
Nature of Injury

Vehicle #2

Name
Age
Nature of 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.