Phone: +1.310.342.5155 Option 2
Need to submit a claim immediately?
Please fill out the Accident/Incident Report Form below and press submit.
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 SUBMISSIONOF THIS FORM. YOU MAY CONTACT THE CLAIMS DEPARTMENT BY CALLING 310-342-5155 OPTION 4.