Incident Report

Fill and complete form to all of the requested information to assist in the investigation and processing of a potential claim. You MUST fill out all boxes and submit photos of incident in order for proper submission.

Failure to provide all of the requested information will delay the response and processing of a potential claim.

Tell the customer the following:

By completing this report, Star Brite Car Wash does NOT accept any responsibility for the stated damage until the claim is investigated by a member of management.

A manager will review the report and photos along with our surveillance footage and will be in touch to discuss the next steps within a few days.

Incident reports MUST be filled out within 72 hours from incident in order to be processed.

Incident reports filed after this timeframe cannot be processed and may not be covered.

Incident Report
Please fill out the form below and submit to out Management team. Be sure to include as many images of any damages.
Customer Name*
First Name Last Name
Email address*
Enter Email Confirm Email
Phone*
Address*
Street Address City State ZIP Code

Which wash location did the incident occur?*
Incident Date*
Incident Time*

Hours :

Minutes

AM/PM
Vehicle Year*
Vehicle Make*
Vehicle Model*
Vehicle Color*
License Plate State*
State
License Plate:*
Vehicle VIN*
Describe the incident in as much detail as possible*
Area of Vehicle in Question*

Insurance Information
If needed, copy all insurance information belonging to the customer. If not necessary for this claim, Press NEXT to continue to next section
Insurance Company Name:
Insurance Company Address
Street Address Address Line 2 City State ZIP Code
Insurance Company or Agent Phone Number
Insured Name:
First Last
Policy Number:
Effective Date:
MM slash DD slash YYYY
Expiration Date:
MM slash DD slash YYYY
Hidden
Please read and understand the following before initialing
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 Thomas 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 Thomas Car Wash with investigating the incident, and that, by completing the claims form, I hereby grant my permission to the Thomas Car Wash to the information contained herein and that this form and any additional information may be sent to Thomas Car Wash’s insurer or others involved in and investigating the incident.

Incident Report

Incident Report

Insurance Information

Please read and understand the following before initialing

Upload up to 10 pictures

Tell The Customer