EmailMe Form - Vehicle Accident or Vehicle Fire Submission Form

Department Name: *

Person Submitting Claim: *

Email Address *

Incident Date: *

MM / DD / YYYY

Incident Number:

Incident Location: *

Physical Address Required

County and State: *

Vehicle #1

Veh. 1 - Owner Name: *

Veh. 1 - Owner Address: *

Include City, State, and Zip Code

Veh. 1 - Owner Phone:

Veh. 1 - Driver Name:

(If different than the owner)

Veh. 1 - Year, Make and Model: *

Veh. 1 - State & License Plate: *

Veh. 1 - VIN: *

Veh. 1 - Insurance Carrier: *

Veh. 1 - Insurance Policy Number: *

Vehicle #2

Veh. 2 - Owner Name:

Veh. 2 - Owner Address:

Include City, State, and Zip Code

Veh. 2 - Owner Phone:

Veh. 2 - Driver Name:

(If different than the owner)

Veh. 2 - Year, Make and Model:

Veh. 2 - State & License Plate:

Veh. 2 - VIN:

Veh. 2 - Insurance Carrier:

Veh. 2 - Insurance Policy Number:

Vehicle #3

Veh. 3 - Owner Name:

Veh. 3 - Owner Address:

Include City, State, and Zip Code

Veh. 3 - Owner Phone:

Veh. 3 - Driver Name:

(If different than the owner)

Veh. 3 - Year, Make and Model:

Veh. 3 - State & License Plate:

Veh. 3 - VIN:

Veh. 3 - Insurance Carrier:

Veh. 3 - Insurance Policy Number:

More than three vehicles involved? Add them to the Incident Narrative box.

At Fault Vehicle

Which vehicle is at fault? *

Select which vehicle is suspected to be at fault in this incident. If you are unsure, select "Unknown".

Invoice at fault party if insurance denies payment, does not pay in full, or if no insurance is supplied? *

What apparatus responded to the incident?

List all unit numbers separated by commas. (ie., Engine 72, Engine 78)

Engines / Pumpers:

Tankers:

Rescues:

Aerial / Ladder Trucks:

Utility / Brush Trucks:

Chief / Command Vehicle:

Any Specialty Equipment?

HazMat Trailer, Rescue Trailer, Light Tower, etc.

Incident Information

Amount of time on the Incident: *

Hours and Minutes

Number of Personnel that Responded: *

Services you provided: *

Extrication, Traffic Control, Leak Control / Containment, Debris Removal, Landing Zone, etc.

HazMat Supplies Used:

Oil Dry, Absorbent Pads, etc. | Include quantity used and cost to replace each item.

Damaged Equipment:

Any equipment / gear receive damage while on scene? If so, list name, type, and cost to clean / fix / replace.

Incident Narrative: *

Describe the incident and what actions you took. Be as detailed as possible.

If more than three vehicles involved include information for additional vehicles in this field.

File Upload

If you have any documents that are related to this incident that you need to include upload them here.