Members are required to fill out an incident report Vehicle #2

any time they are involved in either a minor incident Driver

Hit and Run? Y / N
or a major accident with a Zipcar. Please complete
Name:
each of the sections below in order. You must read
and sign the statement at the end of this form. Injuries? Y / N

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:

Incident Details Injuries? Y / N Injuries? Y/N

Additional Information: Additional Information:

Date (MM/DD/YY):
Passenger 2 Passenger 2
Age (approx): Age (approx):
Time: AM/PM
Full Name: Full Name:

City: Full Address: Full Address:

Phone: Phone:
State:
Injuries? Y / N Injuries? Y / N

Country: Additional Information: Additional Information:

Location Address/Intersection:
Zipcar Nickname: Vehicle Type: Commercial / Passenger

Year: Make: Model: Year: Make: Model:

License Plate & State: License Plate & State:
Damage: Y/N Towed: Y / N Driveable: Y / N Damage: Y / N Towed: Y / N Driveable: Y / N

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

Officer Name & Badge #: 1 13 7 1 13 7

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.

Step 1 Step 2 Step 3 TURN

OVER
 Incident
Description
Direction 1 Zipcar 2 Other Vehicle Pedestrian

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.
Witnesses
to Incident

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

Other: I have a damage fee waiver Y/N

Step 5 Step 6 Send Completed Accident Report Form(s)