CLAIM SUBMISSION

Incident Information

Who is submitting a claim?

Are you a rental car company?
Are you an adjuster?
Are you the driver?

* If you are a current client and have portal credentials, please submit your claim through our Claims Portal

Name of Rental Car Company *

Rental Company Contact Name *
First
Last

Phone *

Name of Insurance Company *

Adjuster Name *
First
Last

Adjuster Phone *

Date and Time of Incident *
Date
Time

Location of Incident *

Was there a police investigation?

Police Department

Driver 1 Information

Name of Driver 1 *
First
Last

Gender

Date of Birth

Briefly describe the facts of the loss:

Briefly describe any injuries:

Driver's License Number

Driver's License State

Vehicle License Plate Number

Vehicle License Plate State

Vehicle Identification Number (VIN)

Vehicle Make and Model *

Briefly describe any vehicle damage: *

Additional Driver Information
No Info For Any Other Driver
I Have Info For 2nd Driver
I Have Info For 3rd Driver
I Have Info For 4th Driver

Additional Information

Include additional property damage, drivers involved, or other notes:

File Upload

Drag & Drop Files, Choose Files to Upload You can upload up to 99 files.

Please upload the following types of documents: Police Report/Driver Exchange/Case Card(s); Insurance Card(s); Driver’s License(s); Rental Agreement; Photo(s)

CAGE NUMBER: 8G7Q3 UEI NUMBER: 054075017

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CLAIM SUBMISSION

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