Renter's First Name*
Renter's Last Name*
Contract Number
Renter's Address*
Additional Renter's First Name*
Additional Renter's Last Name*
Date and Time of Incident*
Location of Incident*
Vehicle Make and Model*
Vehicle License Plate*
VIN
Description of the Accident*
Description of the Damage to the Rental Car*
Renter Signature*
I hereby certify that the above statements are true and correct to the best of my knowledge and belief.*