CUSTOMER ACCIDENT, AUTO INCIDENT OR PROPERTY DAMAGE REPORT
Form Submission Number
Store Location
*
Date Incident Reported
*
-
Month
-
Day
Year
Date
Customer Name
*
First Name
Last Name
Customer Current Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Date of Incident
*
-
Month
-
Day
Year
Date
Time of Incident
*
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Incident Reported to
*
First Name
Last Name
Did this involve damage to a vehicle
*
Yes
No
Color of Vehicle
White, Grey, Black
Make (Manufacturer of vehicle)
Ford, Chevy, Dodge, etc
Model of Vehicle
F150 pickup, Camaro, Camery, etc.
Year of Vehicle
4 digit year
Description of Incident (to be completed by manager/employee and customer
*
Name of Witness to Incident (if any)
*
First Name
Last Name
Supervisor Name
*
First Name
Last Name
Supervisor Phone Number
*
-
Area Code
Phone Number
Today's Date
*
-
Month
-
Day
Year
Date
Employee Name
*
First Name
Last Name
Employee Number
*
-
Area Code
Phone Number
Employee/Store Email
*
example@example.com
DM Email address
*
example@fourteenfoods.com
DO Email address
*
example@fourteenfoods.com
Employee Signature
*
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