Page Content 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) First Name* Required Last Name* Required Your Address* Required City* Required State N/A Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Guam Puerto Rico Virgin Islands Zip Code* Required Phone Number* Required Email* This field is Required / Invalid email address, please check for typos. Date of Incident* Required Invalid Date Format, please use MM/DD/YYYY Time of Incident County Where Incident Occurred* Alamance Alexander Alleghany Anson Ashe Avery Beaufort Bertie Bladen Brunswick Buncombe Burke Cabarrus Caldwell Camden Carteret Caswell Catawba Chatham Cherokee Chowan Clay Cleveland Columbus Craven Cumberland Currituck Dare Davidson Davie Duplin Durham Edgecombe Forsyth Franklin Gaston Gates Graham Granville Greene Guilford Halifax Harnett Haywood Henderson Hertford Hoke Hyde Iredell Jackson Johnston Jones Lee Lenoir Lincoln McDowell Macon Madison Martin Mecklenburg Mitchell Montgomery Moore Nash New Hanover Northampton Onslow Orange Pamlico Pasquotank Pender Perquimans Person Pitt Polk Randolph Richmond Robeson Rockingham Rowan Rutherford Sampson Scotland Stanly Stokes Surry Swain Transylvania Tyrrell Union Vance Wake Warren Washington Watauga Wayne Wilkes Wilson Yadkin Yancey Required Location of Incident* Required Was a state agency or contractor involved? **If contractor is known, contact contractor for claim submittal** Type of Problem* Collision Debris Falls Ferry Low Shoulder Mailbox Misc Mowing Paint Potholes/Pavement Rock Tar/Road Oil Required Brief description of incident* (Please provide the exact location, direction of travel, road name, closest intersection, etc.) Required What kind of property was damaged in this incident?* Motor Vehicle Property Damage Other than a Vehicle Both a Vehicle and Other Property Required 2 Incident Involving a Motor Vehicle (Please fill out only if incident involved a motor vehicle) Private Vehicle Involved in Incident: Vehicle Make* Required Vehicle Model* Required Vehicle Year* Required License Number* Required State* N/A Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Guam Puerto Rico Virgin Islands Required Owner of Vehicle* Required Insurance Company* Required Policy Number* Required Speed of Vehicle at the time of the incident* Required Has the vehicle been repaired?* Required If repaired, state place where it was repaired Cost of Repair* Required Have the repairs been paid for? If the repairs were paid for, who paid for them? If Insurance, what is your deductible? What did the damages consist of?* Required Was anyone injured?* Required If there were any witnesses to the accident, please list names below and their addresses: Witness 1 Name Witness 1 Phone Witness 2 Name Witness 2 Phone Was there a police report? If so, please attach report.* Required 3 Incident Involving Property Damage (Please fill out only if incident involved property damage other than a vehicle) Property Involved in Incident: Address* Required City* Required State* N/A Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Guam Puerto Rico Virgin Islands Required Zip Code* Required Provide any additional comments, attach pictures, estimates, invoices, proof of payment, and other supporting documents related to the incident. Claims that do not provide proof of damages, estimates of repairs / invoices will be denied. If you need to send physical evidence instead of uploading files, please submit a paper form. Attachment 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 denial of my submission and (or) criminal action. Validating Fields Validating Attachment(s) Submitting Form Last updated Apr. 4, 2022