CLAIM REPORTING FORM

All claims will be submitted to and handled by PurCo Fleet Services, Inc. They are claims management company, not a collections agency.

If you need police, emergency medical assistance, or are in an unsafe location, please dial 911. To request Emergency Roadside Service or towing, please call 800-654-5060 for assistance. To complete an accident report online, please complete the form below.

Today's Date *

Name of Person Completing This Form *

Renters Full Name *

Renters Address *

Renters City/State/Zip Code *

Phone *

Email *

Have you contacted your insurance company?

Yes

No

Insurance Carrier *

Insurance Policy Number

Type of Rental

Business

Pleasure

Insurance Replacement

Please provide the rental vehicle information:

Date of Incident *

Time of Incident *

License Plate State

License Plate Number

Rental Agreement Number

Rental Pick Up Location *

LDW Purchased? (Loss Damage Waiver) *

Yes

No

Incident Location

Incident Location *

Other Location Details

Incident Details - Description *

Incident Details - Damage Description

Please upload photos of the damaged vehicle: Include all four corners plus additional pictures of the damage.

Passenger Front Corner Photo

Driver Front Corner Photo

Passenger Rear Corner Photo

Driver Rear Corner Photo

VIN Number

Photo of Vehicle Mileage

Misc Damage Photo

Misc Damage Photo

Miscellaneous Photos 1

Miscellaneous Photos 2

Miscellaneous Photos 3

Miscellaneous Photos 4

Is rental vehicle drivable?

Yes

No

Was the vehicle towed? *

Yes

No

Were the police notified?

Yes

No

Police Agency & Report Number

Police Report Number
Police Agency

Is the driver of the rental vehicle the same as the renter?

Yes

No

Vehicle was not occupied or Unknown

Was another party involved in the accident?

Yes

No

Was anyone injured?

Yes

No

Is the person submitting the incident report the same as the renter?

Yes

No

Additional Notes

As the submitter of this form, I acknowledge that the information is true and correct to the best of my knowledge.