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Accident Report

Contact Claims Department


Phone:+1.310.342.5155 Option 4

Submit A Claim Immediately


Need to submit a claim immediately?
Please fill out out Accident/Incident Report Form below and press submit.

ACCIDENT/INCIDENT GLASS/TIRE
* fields are mandatory

RENTAL VEHICLE INFORMATION

* YEAR/MAKE/MODEL: * UNIT#
* RENTAL AGREEMENT# AREA DAMAGED:
WAS VEHICLE TOWED? TOWED TO:
TOWING COMPANY'S PHONE #

FACTS OF ACCIDENT

* DATE OF ACCIDENT: * TIME:
POLICE DEPARTMENT HANDLING: POLICE REPORT#
* LOCATION OF ACCIDENT (STREET, CITY AND STATE)
DETAILS OF INCIDENT:
INJURIES IN FOX VEHICLES:

RENTER/DRIVER INFORMATION

* RENTER: DOB:
* DRIVER: DOB: M/F
* DRIVERS LICENSE# * STATE:
E-MAIL:
HOME ADDRESS:
HOME PHONE# WORK PHONE#
INSURANCE CO. & PHONE# POLICY#

3rd PARTY VEHICLE INFORMATION

REGISTERED OWNER:
DRIVER: DOB: M/F
DRIVERS LICENSE# STATE:
E-MAIL:
HOME ADDRESS:
HOME PHONE# WORK PHONE#
YEAR/MAKE/MODEL/LICENSE PLATE#
AREA DAMAGED:
INSURANCE CO. & PHONE# POLICY#
INJURIES?
WERE PARAMEDICS OR OTHER MEDICAL PERSONNEL CALLED TO THE ACCIDENT SCENE?

* DATE: * SIGNATURE:
COMPLETED BY:

YOU WILL RECEIVE A COMMUNICATION FROM THE CLAIMS DEPARTMENT WITHIN 2 BUSINESS DAYS OF SUBMISSION OF THIS FORM. YOU MAY CONTACT THE CLAIMS DEPARTMENT BY CALLING 310-342-5155 OPTION 4.