Incident Report Form

Use this form if you have a dispute about your ignition interlock device.

Please allow between 5 – 7 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.
Before proceeding, you must read and agree to the Terms and Conditions for the incident report.*

"*" indicates required fields

Simple Interlock Terms and Conditions*

I have read and agree to the Terms of Service

Disclosure of Terms and Conditions

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 monitoring 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.

Thank You,
Simple Interlock

Select Your State*

Please Complete this Form

Full Legal Name*

First Last

Birthdate*

format as mm/dd/yyyy

Driver's License #*

Email*

Phone*

Date of Incident*

format as mm/dd/yyyy

Time of Incident*

Preferred Method of Contact

Detailed Description of the Incident*

Receipts (optional)

Drop files here or

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

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Incident Report Form

Use this form if you have a dispute about your ignition interlock device.

Please allow between 5 – 7 business days for an official response.

Please Complete this Form

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