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Incident Statement

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This form is used for reporting an incident resulting in property damage or injury that involved the N.C. Department of Transportation. If the name of the contractor involved in the incident is known, please contact the contractor directly.

1 General Information

(Please fill out General Information for either vehicle incident or property incident)




**If contractor is known, contact contractor for claim submittal**

(Please provide the exact location, direction of travel, road name, closest intersection, etc.)

2 Incident Involving a Motor Vehicle

(Please fill out only if incident involved a motor vehicle)

Private Vehicle Involved in Incident:
If there were any witnesses to the accident, please list names below and their addresses:

3 Incident Involving Property Damage

(Please fill out only if incident involved property damage other than a vehicle)

Property Involved in Incident:
Provide any additional comments, attach pictures, estimates, invoices, proof of payment, and other supporting documents related to the incident.
By clicking on the 'Submit' button, I certify I have given true, accurate and complete information on this form to the best of my knowledge. I authorize investigation of all statements made in this submission and understand false information or documentation, or a failure to disclose material information may be grounds for rejection of my submission and (or) criminal action.
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4/4/2022 10:35 AM