Target Park U.S. Main Office:
70 Hudson St. Suite 6B, Hoboken, NJ 07030
|
Phone:
(201) 253 0953
|
Email:
Info@targetparkusa.com
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CUSTOMER INCIDENT REPORT - Target Park
5015
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Customer Incident Report
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CLAIM TYPE
*
COLLISION
THEFT OR PERSONAL INJURY
CUSTOMER COMPLAINT
BODILY INJURY
CLAIMANT
NAME
*
First
Last
ADDRESS
Address Line 1
Address Line 2
City
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
State
Zip Code
HOME PHONE
*
WORK PHONE
TIME AND PLACE
TYPE OF FACILITY
*
COMBINATION OF SELF & VALET
SELF PARK
VALET/ATTENDED
LOCATION NO.
LOCATION NAME
*
LOCATION ADDRESS
Address Line 1
Address Line 2
City
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
State
Zip Code
DATE / TIME OF INCIDENT
*
Date
Time
TICKET NO#
TICKET COLOR
DATE / TIME ENTERED
*
Date
Time
DATE / TIME EXITED
*
Date
Time
NAME OF VALET IN
*
IF VALET OR ATTENDANT PARKED VEHICLE
NAME OF VALET OUT
*
IF VALET OR ATTENDANT PARKED VEHICLE
VEHICLE INFO
RENTAL?
*
Y
N
OWNER OF AUTO
*
Please provide the name of the vehicle lease company if it's a rental.
OWNERS ADDRESS
*
Address Line 1
Address Line 2
City
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
State
Zip Code
Please provide the contact of the vehicle lease company if it's a rental.
VEHICLE MAKE
*
VEHICLE MODEL
*
VEHICLE YEAR
*
VEHICLE COLOR
*
LICENSE PLATE #
*
ODOMETER
*
ESTIMATE AMT. OF LOSS
WHEN INCIDENT OCCURRED, HAD CAR BEEN TURNED OVER TO US?
*
Y
N
HAD CAR BEEN RETURNED TO CLAIMANT?
*
Y
N
WAS CLAIM REPORTED PRIOR TO VEHICLE LEAVING THE FACILITY?
*
Y
N
IF NOT REPORTED, WHY?
INCIDENT AND DAMAGES
INCIDENT DESCRIPTION
*
(MGR Please Describe Incident)
LIST DAMAGES
*
(MGR Please Describe Incident)
PHOTO OF DAMAGES
Click or drag files to this area to upload.
You can upload up to 5 files.
Attach photo if available
CUSTOMER SIGNATURE
*
Clear Signature
DATE
*
MANAGER'S NAME (PRINT)
*
MANAGER'S PHONE
MANAGER SIGNATURE
*
Clear Signature
DATE
*
DAMAGE DESCRIPTION
WHERE WAS VEHICLE DAMAGED?
FRONT
REAR
TOP
DRIVE SIDE
PASS SIDE
WERE STOLEN ITEMS ATTACHED TO AUTO?
Y
N
IF NOT, WHERE WERE ITEMS STOLEN FROM?
FRONT SEAT
BACK SEAT
TRUNK
WAS A POLICE REPORT FILED?
*
Y
N
DATE OF POLICE REPORT
PRECINCT
WITNESS NAME
First
Last
WITNESS ADDRESS
Address Line 1
Address Line 2
City
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
State
Zip Code
WITNESS PHONE
Submit
EN
ES
