Completed Incident Report Form(s) UBER ATTN Legal Email: egal @uber.com Fax 877-223-8023 Mail: Uber Technologies In., 405 Howard St. #550, San Francisco, CA 94105 Uber drver-partners are required to fil outan incident report each time they are involved in a minor or major accident -while en route to pick up a Fider, or during a tp when arideris in the vehicle. If an accident does occur, frst secure the scene and seek medical attention ifnecessary. Notify the police immediately so a police report can be filed. If possible take pictures of vehicle and /or property damage and send with this form. Rotum this signed form to Uber within 24 hours and reach out to your personal Insurance car Date: Time: _Addess intersection Civ. Stat, County: Police Involve ment (Y/N Pole Report: ‘OffcerName & Badge # Pale Precnet/Deparinent Partnor Name: Passenger 1 Name: Passenger Name: Driver's License @, State ge (oops ‘ee (901): Phone ae: Sex| Phone Phone ‘adress aes ‘eres ‘ofOceupants (inslude self Injurea? wea? Were youinjurea? ‘ional information ‘Additonal Information: ‘Addon Information Carinformation Year Make, Model License Plate /State Damaged, Towed, Diveable? oo Oo o o a Tl Pnseinican damage act tsar. (Undere arias. Owraimed, Ofer) Dror tame: avenger Name: Pasener2 Name: Divers lies & Su Ze (pth 2 pn) Phone [Se | Phone Phone a 7 aie *FofOseupants nelude sei | DB: Injwee? Injured? ines? inant "al rma Tern Carin Pome Poly ‘naira arinfomation Year Mae, Mode Teese Paws Damaged Tove. Diese? Titan an? oo oOo OG o a O Please indicat the damaged area ofthe car (Undereaiage, Orertumed Other)Wines 1 Wines 2 ese Paes Phone Phone Td 5 Darlignt Dawn a Dy Sand/Mud/Granel—) FourViay Cj Notanintrsection Dust Davkstigned — Clouty > Fog/Smote Snow Water Standing raffle) Tnterseeton 1 Dart -Not Lighted he Oa Wet 5 WawrMouing 1 Driveway] Ralload Crossing 2 Ofer: Rain Snow Oke 1D Patkingtot —C] on/offRamp Blowing Sand/Snow 0 otter: 1D Vanteseetion Cl 5 PointorMore 1 Ofer: oer: Incident Description i O ‘scarey as possible, draw a diagram ofthe roadway orinteseeton where the acident occured, involved partes, waffe signals oral partes, and any therimportant fztrs to elp us understand the incident lee on the tp night. ) winicate direeton of vae lease also indicate “norfr by an arowin the O In your own words, please describe the incident you hate drawn above Please be as specifi and deseiptve as possible ‘ire any citations issued at te see? (Deseribe) Was there property damage? («. guardal. road sign, building, wallet. Deserbe below. By signing below, youhereby acknowledge te above statement a5 wel as agre thatthe informaton provided in tis reports wut t thebestof your knowledge Signature Printed Name ate