Accident/Incident Report

AVIS Renter Information

(To be completed by Renter only)

Which location did you rent from?

Renter's Name

First Last

Renter's Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

License Number State Issued DOB

Home Phone Cell Phone

Email

Insurance

Insurance Company Insurance Policy Insurance Agent

Insurance Phone # Claim #

Credit Card Damage Coverage? C/C Phone # C/C Claim #

Rental Vehicle

Year License Plate Vehicle Number Make Model

Employer Name

Employer Phone

Employer Address

Email Address

3rd Party (Other Driver)

3rd Party Name

First Middle Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

DOB

Driver License #

State Issued

Home Phone Cell Phone

Email

Insurance

Insurance Company Insurance Policy # Insurance Agent

Insurance Phone # Claim #

Car Make/Model/Year

Vehicle

License Plate Year Make Model

Collision Description

Date of Accident/Incident

Time

: HH

MM

Weather Condition

Location of Incident

Police Report (if applicable)

If ticket was issued, to whom and reason:

Describe how the accident happened, including direction of travel and traffic controls:

List any injured parties and include contact info:

Full Name	Address	Phone #	Injuries	Age

List any witnesses and include contact info:

Full Name	Address	Phone #

Signature

Electronic Signature Date