Members are required to fill out an incident report any time they are involved in either a minor incidentor a major accident with a Zipcar. Please complete each of the sections below in order. You must read and sign the statement at the end of this form. Vehicle #2 Driver Hit and Run? Y / N Name: Injuries? Y / N Drivers License #: License State: DOB: Sex: M / F Zipcar: Vehicle #1 Driver Zipcard #: Member? Y / N Name: Phone: Cell: Address: Completed Incident Report Form(s) Fax: 617.995.4300 Email: [email protected] Mail: Zipcar, Inc. Attn: Incident Reports 25 First Street, 4th Floor Cambridge, MA 02141 Were you injured? Y / N Drivers License #: License State: Phone: Address: City: # of Occupants (include self): Additional Information: Passenger 1 Sex: M / F DOB: City: State: Zip: State: Zip: # of Occupants (include driver): Insurance Carrier: Phone: Policy: Age (approx): Passenger 1 Age (approx): Full Name: Full Address: Phone: Full Name: Full Address: Phone: Injuries? Y/N Additional Information: Passenger 2 Incident Details Date (MM/DD/YY): Injuries? Y / N Additional Information: Passenger 2 Time: City: State: Country: AM/PM Age (approx): Age (approx): Full Name: Full Address: Phone: Injuries? Y / N Additional Information: Full Name: Full Address: Phone: Injuries? Y / N Additional Information: Location Address/Intersection: Zipcar Nickname: Year: Make: Model: Vehicle Type: Commercial / Passenger Year: Make: Model: License Plate & State: Damage: Police Involvement: Y / N Police Report #: Officer Name & Badge #: Y/N Towed: Y / N Driveable: Y / N License Plate & State: Damage: Y / N Towed: Y / N Driveable: Y / N Please indicate the damaged area of Vehicle 2: Please indicate the damaged area of the Zipcar: 2 1 12 3 13 4 5 6 7 8 1 2 3 13 4 5 6 7 8 Police Precinct/Department: 11 10 9 12 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. Step 1 Step 2 Step 3 TURN OVER Incident Description Direction 1 Zipcar 2 Other Vehicle Pedestrian Witnesses to Incident As carefully as possible, draw a diagram of the roadway or intersection where the accident occurred. Please use the symbols (above) to indicate direction of travel, involved parties, traffic signals for all parties, and any other important factors to help us understand the incident. Witness 1: Address: City: Daytime Phone: Witness 2: Address: City: Daytime Phone: State: State: Indicate North by an Arrow Conditions Light Conditions Daylight Dusk Dark – Not Lighted Other: Weather Conditions Dawn Dark – Lighted In your own words, please describe the incident you have drawn above. Please be as specific and descriptive as possible: Cloudy Snow Hail High Winds Clear Rain Ice Fog / Smoke Other: Road Surface Blowing Sand / Snow Were any citations issued at the scene: (describe) Wet Ice Water Moving As stated in the membership agreement, members are responsible for a damage fee per incident. Visit zipcar.com for more information on damage fee charges. By signing below, you hereby acknowledge the above statement, as well as agree that the information provided in this report is truthful to the best of your knowledge. Y-Intersection 5 Point or More Railroad Crossing Printed Name Date Signature Dry Snow Water Standing Other: Intersection Type Was there property damage (i.e., guardrail, road sign, building, wall, etc.)? Describe below: Sand / Mud / Gravel Not an Intersection Four-way T-Intersection On / Off Ramp Traffic Circle Driveway Parking Lot Other: I have a damage fee waiver Y/N Step 5 Step 6 Send Completed Accident Report Form(s)