- EST. 1946 -

INCIDENT REPORT

Full and complete responses to all of the requested information will assist in the investigation and processing of your potential claim. NOTE - You MUST fill out all boxes and submit photos of incident report in order for proper submission. Failure to provide all of the requested information will delay the response and processing of your potential claim. Incident Reports MUST be filled out within 72 hours from incident in order to be processed. Incident reports filed after this timeframe cannot be processed and will not be covered. This is only for our Nicholasville location. Our other Thomas Car Wash locations have retired. Please contact Whistle Wash for help with our retired locations.

Incident Report

Legal First Name:

Legal Last Name:

Phone:

Which wash location did the incident occur?

NICHOLASVILLE

CLEMENTINE

Date the incident occured: MM/DD/YYYY

Time the incident occured: (Please use time on receipt if you have one)

Vehicle Year:

Vehicle Make:

Vehicle Model:

Vehicle Color:

License Plate #:

Please describe the incident in as much detail as possible

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Please read and understand the following before initialing:

I state that my answers on this form are true and correct to the best of my knowledge. I certified that the timeframe of this claim is true to the best of my ability. I also understand that submitting this form does not indicate that Thomas Car Wash has accepted responsibility for this matter and that responsibility will be determined after further investigation and analysis of the facts and circumstances relating to the incident. I further understand and agree that I am providing the requested information voluntarily in order to assist Thomas Car Wash with investigating the incident, and that, by completing the claims form, I hereby grant my permission to the Thomas Car Wash to the information contained herein and that this form and any additional information may be sent to Thomas Car Wash’s insurer or others involved in and investigating the incident.

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