Please complete all sections of this form that are relevant to your claim to the best of your knowledge.
Claimant Information
First Name:
Middle Name:
Last Name:
Date of Birth:
Full Street Address: (Please no P.O. Box)
City:
State:
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
――――
American Samoa
Guam
Northern Mariana Islands
Puerto Rico
United States Minor Outlying Islands
Virgin Islands
――――
Armed Forces Americas
Armed Forces Pacific
Armed Forces Others
Zip Code:
Telephone: (Home)
Telephone: (Cell)
Email:
Gender:
Male
Female
Trans
Other
Social Security #: (last 4 digits)
TransPass #:
Weekly/Monthly/Zone #:
Incident Information Please provide us with as much information pertaining to the incident as possible
Date of Incident:
Time of Incident:
Location:
Incident Type: (Please check ONE of the boxes)
Bodily Injury
Property Damage
Both
Incident Card #:
SEPTA Vehicle Information If your incident involved a SEPTA vehicle (Bus, Trolley, Train, etc. please complete this section (Questions are designed for us to locate you on our Vehicle Cameras)
Vehicle #:
Route #:
Block:
Where did you board the vehicle:
Destination:
(Please check the appropriate box to indicate your position on the SEPTA vehicle at the time of the incident)
Were you ____ on the SEPTA vehicle?:
Boarding
Exiting
Sitting
Standing
If Sitting, were you situated/positioned next to the ____ on the vehicle?:
Window
Aisle
Sideway Facing Section
Were you on the ____ of the vehicle?:
Driver Side
Door Side
Were you in ____ the middle doors?:
Front
Behind
Was the vehicle:
Moving
Stopped
At the time of the incident were you wearing any distinctive colors or articles of clothing:
SEPTA Employee Information Please complete the section that is relevant to you
If Employee Details are KNOWN
Full Name of SEPTA Employee(s) (Driver, Cashier, Conductor) Involved, or at the scene
If Employee Details are NOT KNOWN please provide description
Gender:
Male
Female
Trans
Other
Race/Ethnicity:
Age:
Height:
Weight:
Additional Description:
Bodily Injury Details Were you injured? if so, please complete this section
Details of Injury:
Side of Body:
Left
Right
Both
Medical Attention:
Yes
No
Were you transported to hospital from scene?:
Yes
No
Hospital/Medical Center Details:
Attending Physician:
Property Damage Details Has your property been damaged? If so, please complete this section
Details of Damage:
Car:
Yes
No
Owner of Vehicle:
Yes
No
Make & Model:
Year:
Tag #:
Vin #:
Insurance Company:
Policy #:
Do you have Scene Photos or Photos of the Damaged property
Yes
No
Damage Estimate:
Yes
No
SEPTA Premises Information If your incident happened on our Premises, please complete this section
Specific Location:
What caused your injury:
Ice/Snow
Dirt/Debris/Liquid
Defect
Other
If you selected Defect, please explain:
If you selected Other, please explain in detail:
Do you have scene photos or photos of the damaged property?:
Yes
No
If yes, can you send them?:
Yes
No
Employment Information
Name of Employer:
Address:
Telephone Number:
City:
State:
State
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
――――
American Samoa
Guam
Northern Mariana Islands
Puerto Rico
United States Minor Outlying Islands
Virgin Islands
――――
Armed Forces Americas
Armed Forces Pacific
Armed Forces Others
Zip Code:
Type of Job:
Salary:
Time Out of Work:
Claims Summary Information Please describe the Accident/Incident as fully as possible in your own words
Claims Summary:
I certify that the above statements are true to the best of my knowledge, information and belief. I understand that the giving of false statements regarding a claim is a crime and that if I do give false statements, I may be subject to criminal prosecution.
Confirm
Please complete the "captcha" by clicking the "I'm not a robot" check box (required): *