Date of Incident:

Time of Incident:

Location of incident:

Route/Line/Property:

Destination:

Were you: On a SEPTA vehicle/Involved with a SEPTA vehicle On SEPTA property other than vehicle

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 #:

Date of Incident:

Time of Incident:

Location:

Incident Type: (Please check ONE of the boxes) Bodily Injury Property Damage Both

Incident Card #:

Vehicle #:

Route #:

Block:

Where did you board the vehicle:

Destination:

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:

Full Name of SEPTA Employee(s) (Driver, Cashier, Conductor) Involved, or at the scene

Gender: Male Female Trans Other

Race/Ethnicity:

Age:

Height:

Weight:

Additional Description:

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:

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

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

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:

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):*