Incident Statement

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

City

State

Zip Code

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*

Required

Location*

Required

Was a state agency or contractor involved? **If contractor is known, contact contractor for claim submittal**

Type of Problem*

Required

Brief description of incident (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:

Vehicle Make

Vehicle Model

Vehicle Year

License Number

State

Owner of Vehicle

Insurance Company

Policy Number

Speed of Vehicle at the time of the incident

Has the vehicle been repaired?

If repaired, state place where it was repaired

Cost of Repair

Have the repairs been paid for?

If the repairs were paid for, who paid for them?

What did the damages consist of?

Was anyone injured?

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.

3 Incident Involving Property Damage

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

Property Involved in Incident:

Address

City

State

Zip Code

Provide any additional comments, attach pictures, estimates, invoices, proof of payment, and other supporting documents related to the incident.

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

4/4/2022 10:35 AM