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Drivers License #:
Zipcar: Vehicle #1 License State: Sex: M / F
Driver
Zipcard #: DOB:
Name: Member? Y / N Phone:
Were you injured? Y / N
Completed Incident Cell:
Drivers License #:
Report Form(s) Address:
License State: Sex: M / F
City:
Fax: 617.995.4300 Phone: DOB:
State: Zip:
Email: accidents@zipcar.com Address:
# of Occupants (include driver):
City: State: Zip:
# of Occupants (include self): Insurance Carrier:
Mail: Zipcar, Inc.
Attn: Incident Reports Additional Information: Phone:
25 First Street,
4th Floor Policy:
Cambridge, MA 02141 Passenger 1 Passenger 1
Age (approx): Age (approx):
Full Name: Full Name:
Full Address: Full Address:
Phone: Phone:
Date (MM/DD/YY):
Passenger 2 Passenger 2
Age (approx): Age (approx):
Time: AM/PM
Full Name: Full Name:
Location Address/Intersection:
Zipcar Nickname: Vehicle Type: Commercial / Passenger
Police Involvement: Y / N Please indicate the damaged area of the Zipcar: Please indicate the damaged area of Vehicle 2:
Police Report #: 3 4 5 3 4 5
2 6 2 6
12 8 12 8
Police Precinct/Department: 11 10 9 11 10 9
14: Undercarriage 15: Overturned 16: Other 14: Undercarriage 15: Overturned 16: Other
If there are other vehicles involved in the incident, please copy this page and fill out the information for Vehicle 3, 4, etc.
Witness 1:
Address:
Indicate
City: State: North by
an Arrow
Daytime Phone:
Witness 2:
Address:
City: State:
Daytime Phone:
Conditions
Light Conditions
Daylight Dawn
Dusk Dark – Lighted
Dark – Not Lighted In your own words, please describe the incident you have drawn above. Please be as specific
Other: and descriptive as possible:
Weather Conditions
Clear Cloudy
Rain Snow
Ice Hail
Fog / Smoke High Winds
Blowing Sand / Snow
Other:
Road Surface
Were any citations issued at the scene: (describe)
Dry Wet
Was there property damage (i.e., guardrail, road sign, building, wall, etc.)? Describe below:
Snow Ice
Sand / Mud / Gravel
Water Standing Water Moving
Other:
As stated in the membership agreement, members are responsible for a damage fee per
Intersection Type
incident. Visit zipcar.com for more information on damage fee charges. By signing below,
Not an Intersection you hereby acknowledge the above statement, as well as agree that the information
Four-way provided in this report is truthful to the best of your knowledge.
T-Intersection Y-Intersection
On / Off Ramp
Signature
Traffic Circle 5 Point or More
Driveway Railroad Crossing
Parking Lot Printed Name Date