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mv 104 form

ACCR 701012 2015-2024 free printable template

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Fax to (6) UnitedHealthcare 3120 South Capitol Street Mountain View, CA 94043 Phone: Fax: All Plans (except HSA) (1) Blue Shield of California 5501 W. Olympic Blvd., STE 110 Los Angeles, CA 90029 Phone: (2) California Health Benefit Exchange 1612 K St., Ste. 120 Oakland, CA 94612 (3) Alliance 2501 N. Lincoln Parkway Suite 500M Los Angeles, CA 90 Phone: (4) California Health Benefit Exchange 2414 W. Olympic Blvd, Ste. 300 Los Angeles, CA 90 (5) UnitedHealthcare 8100 Wilshire Boulevard, Ste. 20101 Los Angeles, CA 90012 Phone: (6) Safeway 100 N. Pacific Ave. Ste. 400 San Bruno, CA 94903 Phone: (6) American Family Insurance 12600 Van Nuys Blvd. Van Nuys, CA 91406 Phone: (7) Allianz 500 N. Broadway Los Angeles, CA 90025 Phone: Fax: All Plans (except HSA) (1) Anthem Blue Cross Blue Shield of California 1290 S. Spring St.

Who needs a Vehicle Incident Report?

This form is completed by a driver of a rental vehicle in case this vehicle was involved in an incident. As a rule, the incident results in damage to a rental vehicle.

What is the purpose of the Vehicle Incident Report?

The report contains the information about the customer (renter), rental agreement, insurance and policy, description of the incident. These details are used by the rental company to investigate the incident and determine the amount of coverage which should be paid to the rental company.

What documents must accompany the Vehicle Incident Report?

The Incident Report is accompanied by the corresponding rental agreement and copies of the driver’s license.

When is the Vehicle Incident Report due?

The driver has to complete and send the form within ten days after the incident.

What information must be provided in the Vehicle Incident Report?

The renter will add the following information:

  • Date of completing
  • Number of the Rental Agreement or Trip Ticket
  • Vehicle owning area number
  • Vehicle unit number
  • Mileage
  • Information about the employee accident (of applicable)
  • Date and time of incident
  • Location of incident
  • Police information (name of officer, badge number, phone number)
  • Customer’s name, e-mail, address
  • Name of customer’s insurance and policy
  • Insurance phone number
  • Name of customer’s employer and address
  • Type of rental business
  • Information about the driver of the rental vehicle (if other than renter)
  • Information about the driver or owner of the other vehicle (name, address; vehicle make and year, license plate; occupants in vehicle, description of the damage to vehicle or property)
  • Information about the injured or killed persons (name, age, sex, phone number)
  • Information about the witnesses
  • Explanation of the cause of damage

The renter must also sign the report and answer all the questions at the bottom of the report.

What do I do with the form after its completion?

The completed form is forwarded to HIM at 1-866-295-0745.

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Instructions and Help about hertz report claim form
Tonight some Florida consumers are finding themselves on the other side of the law for doing nothing more than driving a rental car contact five investigator Katie Lagoon details these incidents and the Florida based rental car company now on the defense reliving it is unbearable these consumers sharing the tales of renting a car Border Patrol agents fully vested armed and being accused of stealing it by the Florida based rental giant Hertz I was in jail for about 15 to 16 hours seven hours I was detained there in that locked area last year this Ohio grandmother was detained at the Canadian border I'm terrified after she was accused of stealing a car she rented from a Hertz agent in Ohio turns out the car belonged to another rental company that reported it stolen a few days earlier when it gave me a stolen car she hired an attorney so has Mali Sterling who says her 2017 rental from her Hertz in South Florida left this mother of one facing the barrel of multiple guns, and I'm like what's going on, and he goes, and I'm like what I said that's impossible because Sterling ended up in jail in her police report she stated she did not return the vehicle despite the employee asking her but sterling tells us that's because Hertz agreed instead of returning the car Thursday she could do it Monday after I got out of job there was a kitchen assistant and now were talking about 10 20 30 cases all over the country her attorney Francis Alexander says Hertz's glitch has created a company pattern of wrongly reporting cars stolen and customers he says pay the price the problem is that Hertz has broken computer systems they have broken policies or rather than filed or standard operating procedures and as a result good people good ordinary citizens are being thrown in jail but Hertz which processes tens of millions of rentals each year is driving home another point false reports of stolen vehicles are extremely rare a company spoke person told us in the statement when it has occurred and has been the result of unique and extenuating circumstances in the rare instance an error within our control has occurred we take responsibility what can you do bizarre incidents have consumer protection experts who love to give advice at a standstill you will find yourself in a difficult position it sounds like the plot of a movie if that's the case the end of Mali Sterling's movie is still in the works I've been 2 years she pled not guilty to a third degree felony for failing to return a rental car in response of hurt says filing a police report is a last resort and maintains it followed its overdue rental process did you fail to return I paid for the car you guys reported it stolen while I'm driving it 7 longest hours of my life Dina Johnson's movie is also still playing out in lawyer talks one year after Hertz put this grandma behind the wheel of someone else stolen car the humiliations I'm just in shock Katie Lagoon IPTV News Channel 5


  • What information must be reported on hertz accident report claim?
    The information required for a Hertz Accident Report Claim includes: 1. Date, time and location of the accident. 2. Names, addresses and phone numbers of all drivers and passengers involved in the accident. 3. Driver's license information of all drivers. 4. Vehicle information of all vehicles involved in the accident. 5. A brief description of the accident and any significant events leading up to it. 6. Contact information of any witnesses to the accident. 7. Photos of the accident scene, if available. 8. Any police reports or other documents related to the accident. 9. Any medical information related to injuries suffered from the accident. 10. An itemized list of all damage and repair costs associated with the accident.
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