Auto Accident Form

Pinnacle Automotive Hospitality Services
601 S. Magnolia Avenue
Tampa. FL 33606
Completed Reports MUST be sent to Human Resources (24 hrs.)

Claim Information

Claimant First Name

Claimant Site Location

Claimant Last Name

Claimant Street Address

Reported Date

Claimant City

Site Manager's Full Name

Claimant State

Site Manager's Contact Phone Number

Claimant Zip Code

Area/Regional Manager Full Name

Department

Accident Information

Accident Location

Accident Location (Text)

Accident Type

Accident Street Address

Date of Accident

Accident Time

Hour

Minute

A/P

AM/PM

Accident City

Accident State

Number of Vehicles Involved

Accident Zip Code

Third Party Responsible?

Department: Automobile or Detail

Police called to Scene?

Police File Number

Vehicle Towed?

Where was Vehicle Towed?

Witness Statement?

Property Damage?

Passengers in Vehicle?

Video or Security Footage Available?

Narrative of What Happened (Who, What, Where, When, Why)

Picture of Damage 1

Picture of Damage 2

Picture of Damage 3

Picture of Damage 4

Estimate or Repair Order (if available)

Associate Responsible

Driver an employee?

Associate Responsible Street Address

Associate Responsible First Name

Associate Responsible City

Associate Responsible Last Name

Associate Responsible State

Associate Responsible Phone Number

Associate Responsible Zip

Associate Responsible Statement

Input Your Email Address to Receive Confirmation of Your Submission

By selecting the "I agree" checkbox, you agree that all information contained in "Associate Responsible" is valid.

I agree

Associate Responsible Name

Witness Information

1st Witness Name

1st Witness Telephone Number

2st Witness Name

2st Witness Telephone Number

Weekly Call Recap Questions

A brief explanation of the claim, is everyone ok?

What was happening at the site that caused the claim to happen?

Was this a Red Tag vehicle?

If yes, was the employee(s) involved in this claim certified to drive this Red Tag vehicle?

Is there an existing policy on your Site-Specific Claims Policy to prevent this claim?

If yes, did the Team Member(s) involved in this claim sign off on the Site-Specific Policy?

How many days before this claim had it been since this team member(s) last Driver's Evaluation?

How many days had the site been claims free before this claim occurred?

What can be done to ensure a claim like this does not happen again?

Estimated cost of the claim?

Was PDA called, only if the claim is estimated over $1,500 (Regional Director discretion)