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
Date Format: MM slash DD slash YYYY
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 #

AVIS Renter Information