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Report A Claim
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LOGIN
About Us
Who We Are
Who's In Charge
Where We'll Be
Insurance
What We Insure
Auto Rental
Commercial Auto & Garage
Commercial Driving Schools
Commercial Excess Automobile Liability
Commercial Explosives
Limousine
Long-Haul Trucking
Motorcoach
Vanpool
Policyholders
Policyholder Resources
Producers
Become A Lancer Producer
Auto Rental
Commercial Auto & Garage
Commercial Driving Schools
Commercial Excess Automobile Liability
Commercial Explosives
Limousine
Long-Haul Trucking
Motorcoach
Vanpool
Claims Center
Report A Claim
After An Accident
Loss Recovery
Fighting Fraud
Safety Stop Blog
Contact
LOGIN
Auto Rental Accident Report Form
INSURED INFORMATION
Insured Name:
Policy Number:
Insured Address:
Insured City, State & Zip Code:
Insured Phone:
(###)
###
####
Contact Person:
*
First Name
Last Name
Account Name:
AWD# (if applicable):
Deductible Amount:
RENTER/CUSTOMER INFORMATION
Renter/Customer Name:
Renter/Customer Address:
Renter/Customer City, State & Zip Code:
Renter/Customer Phone:
(###)
###
####
INSURED VEHICLE
Insured Vehicle Number:
Insured Vehicle License Plate Number:
Insured Vehicle State:
Insured Vehicle Year, Make & Model:
Mileage/Odometer Reading At Time of Accident:
Name of Person Operating Vehicle:
Age of Person Operating Vehicle:
Phone of Person Operating Vehicle:
Address of Person Operating Vehicle:
City, State & Zip Code of Person Operating Vehicle:
Operator's License Number:
State of Issuance:
Expiration Date:
MM
DD
YYYY
Employer Phone:
Employer Address:
Employer City, State & Zip Code:
What Purpose was Vehicle Being Used For At Time Accident Occurred?
Personal
Business
If Business, For Whom?:
Rental Was Paid By:
Cash
Credit Card
Travel Voucher
Other
CLAIMANT
Name of Owner:
Owner Address:
Owner City, State & Zip Code:
Owner Phone:
(###)
###
####
Operator’s Name (If Different From Above):
Operator’s Address:
Operator’s City, State & Zip Code:
Operator’s Phone:
(###)
###
####
Operator’s Vehicle Year, Make & Model:
Description of Property Damaged:
Was Car Drivable?:
Yes
No
Operator’s License Number:
State of Issuance:
Expiration Date:
Operator’s Insurance Company Name:
Operator’s Insurance Company Address:
Operator’s Policy Number:
Operator’s License Plate Number:
Operator’s License Plate State:
INJURED PARTIES
Injured Party 1 Name:
First Name
Last Name
Injured Party 1 Address:
Injured Party 1 City, State & Zip Code:
Injured Party 1 Nature of Injury:
Injured Party 1 Age:
Injured Party 1 Location at Time of Accident:
Pedestrian
Our Vehicle
Other Vehicle
Injured Party 2 Name:
First Name
Last Name
Injured Party 2 Address:
Injured Party 2 City, State, Zip Code:
Injured Party 2 Nature of Injury:
Injured Party 2 Age:
Injured Party 2 Location at Time of Accident:
Pedestrian
Our Vehicle
Other Vehicle
Injured Party 3 Name:
First Name
Last Name
Injured Party 3 Address:
Injured Party 3 City, State, Zip Code:
Injured Party 3 Nature of Injury:
Injured Party 3 Age:
Injured Party 3 Location at Time of Accident:
Pedestrian
Our Vehicle
Other Vehicle
WITNESSES
Witness 1 Name:
Witness 1 Address:
Witness 1 City, State & Zip Code:
Witness 1 Phone:
(###)
###
####
Witness 2 Name:
Witness 2 Address:
Witness 2 City, State & Zip Code:
Witness 2 Phone:
(###)
###
####
ACCIDENT INFORMATION
Date of Report:
MM
DD
YYYY
Date of Accident:
MM
DD
YYYY
Time of Accident:
Weather Conditions:
Police Precinct/Dept. Reported to Accident:
Accident Site:
Accident City, State & Zip Code:
Provide a Brief Description of Accident:
Was Ticket Issued?:
Yes
No
If Yes, Reason:
Rental Operator:
Operator (If Other Than Renter):
Rental Agreement Number:
Date:
MM
DD
YYYY
Description and Estimate of Damage:
Vehicle Towed?:
Yes
No
If Towed, By Whom?:
Thank you!
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