Get stranded drivers the right truck, first time — location, vehicle, and problem in one request.
Automotive template · 8 fields (8 required) · ~2 min for respondents to complete · Free plan · No credit card · Fully customizable
About this form
When someone requests roadside help, the dispatcher needs four things immediately: where the driver is, what the vehicle is, what went wrong, and whether anyone is in danger. This form collects exactly that, in that order of importance, so your team can dispatch the right service — jump start, tire change, lockout, fuel, or tow — without a back-and-forth phone call.
The emergency status field is the triage switch: requests flagged as unsafe (highway shoulder, extreme weather, medical concern) can be prioritized ahead of routine calls.
Best practices
Put this form behind a short link or QR code on membership cards and stickers — nobody remembers a URL while standing on a shoulder.
The location field matters more than anything else. Encourage cross-streets or mile markers in the placeholder text; "near the Shell station" costs your driver twenty minutes.
Pair the form with an instant confirmation (email or SMS webhook) that states an ETA — the silence after requesting help is where customer trust dies.
Review problem descriptions weekly: they tell you which services to staff for and which vehicles keep appearing.
Every field, explained
Driver Name (Name, required)
Phone Number (Phone, required)
Current Location (Address, required) — The dispatch-critical field. Cross-streets, exit numbers, or mile markers beat street addresses on highways.
Vehicle Make/Model (Short text, required)
License Plate (Short text, required) — Lets your operator confirm they found the right vehicle — and protects against fraudulent requests.
Service Needed (Dropdown, required) — Determines which truck rolls. A wrong guess here is a second dispatch, so the options are deliberately plain-language.
Problem Description (Long text, required)
Is this an emergency? (Single choice, required) — Your triage flag. Unsafe-location requests jump the queue.
Frequently asked questions
What should a roadside assistance request form include?
At minimum: the driver’s name and phone, precise current location, vehicle description and plate, the service needed, and whether the situation is unsafe. This template includes all six plus a free-text problem description for anything unusual.
Can drivers submit this form from a phone?
Yes — the form is mobile-first, which is essential since virtually every submission happens from the roadside. Keep it short: this template asks only eight questions.
How do I use this form for a roadside assistance application or membership?
This template handles service requests. For membership applications, duplicate it and swap the incident fields for plan selection and billing details — both forms can run side by side on your site.