Gustafson Brothers Automotive > Rental Request - Insurance Pay

Rental Request

First Name *
Last Name *
Email Address *
Address 1
City
State
Zip Code
Phone Number *
Date Requested *
Time Requested *
Responsible Insurance Company *
Claim Number *
Date Accident or Loss Occured *
Adjuster First, Last Name
Allowance per day (ex; $30.00 or 80%) *
Disclosure *	I understand that I must provide a valid drivers license and major credit card. The name on the credit card must match the name on the driver’s license. I understand that Hertz may make an authorization on the card as a security deposit. Bank issued debit cards are allowed, however I understand that a portion of the funds in my checking account may be on hold and not available for my personal use. I also understand that Hertz requires credit verification on all rentals using debit cards. Hertz will verify direct bill acceptance from insurance company. I will be responsible to re-fuel the vehicle upon return and provide insurance. I will receive full disclosure at time of rental.
Comments

| | | Login