Incident Report

I state that my answers on this form are true and correct to the best of my knowledge. I certified that the timeframe of this claim is true to the best of my ability. I also understand that submitting this form does not indicate that Star Brite Car Wash has accepted responsibility for this matter and that responsibility will be determined after further investigation and analysis of the facts and circumstances relating to the incident. I further understand and agree that I am providing the requested information voluntarily in order to assist Star Brite Car Wash with investigating the incident, and that, by completing the claims form, I hereby grant my permission to the Star Brite Car Wash to the information contained herein and that this form and any additional information may be sent to Star Brite Car Wash’s insurer or others involved in and investigating the incident.