Incident Report Form

Incident Report

"* (Required)" indicates required fields

Before proceeding, you must read and agree to the Terms and Conditions of Service for the Incident Report:

Serviced in Last 30 Days* (Required)

I confirm that my device has been serviced in the last 30 days

I understand that failure to service my device before submitting an Incident Report form may result in a rejection of my request.

Terms and Conditions* (Required)

Terms and Conditions of Service
The Incident Report form gives you, the client, an opportunity to explain the circumstances surrounding an event with your Ignition Interlock Device. Please understand your state authority oversees the ignition interlock program and your state certifies all Ignition Interlock Devices.

A violation reset condition can be caused by the following events:

Ingested Alcohol
Mouth Contaminate – Eating or drinking while taking a required breath test
Skipped or Missed Random Tests
Service Lockout – Missed appointment

If your violation reset condition or service lockout was caused by one of the above events a refund will not be issued.

Credits will not be issued when the violation is found to be user error; such as skipped or missed random tests, eating or drinking while taking a test and all violations caused by ingested alcohol. There are limited exceptions to this rule.

A certified Ignition Interlock Device must enter into a violation reset when the restricted operator has:

Recorded a random test failure;
Disconnected the control head after start up;
Failed to submit to a random retest;
Failed to have the Ignition Interlock Device serviced within the time period described in the regulations of the state.

If you feel that your incident is reviewable after reading the above disclosure please complete the following Incident Report form.

I have read and agree to the Terms and Conditions of Service

State* (Required)

Please Complete the Following Details

Full Legal Name* (Required)

First Last

Birthdate* (Required)

Driver's License #* (Required)

Email* (Required)

Phone* (Required)

Date of Incident* (Required)

Time of Incident* (Required)

Preferred Method of Contact

Detailed Description of the Incident* (Required)

Receipts

Drop files here or

Accepted file types: jpeg, jpg, png, pdf, doc, docx, xls, xlsx, Max. file size: 25 MB, Max. files: 5.

Please allow between five to seven business days for an official response.

Refunds are determined on a case-by-case basis and are not guaranteed for all clients submitting the form below.

Please allow ten business days for an official response.

Refunds are determined on a case-by-case basis and are not guaranteed for all clients submitting the form below.

By submitting this form, you agree and consent for RoadGuard Interlock and its affiliates to use automated technology, including emails, calls, texts, and prerecorded messages, to contact you at the information provided. No purchase necessary; message and data rates may apply.

Incident Report Form

Use this form to request a credit or reimbursement of lockout fees, or to request a credit or reimbursement of tow charges (receipt required).

Incident Report

Please Complete the Following Details

Please allow between five to seven business days for an official response.

Please allow ten business days for an official response.

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