Rental Agreement

Rental Agreement

Please fill out this form for a rental van.
Full Name*

First NameLast Name
Street Address 1:*
Street Address 2:
City:*
State:*
Zip Code:*
Driver's License:*
State Driver's License Issued In:*
Driver's License Expiration Date*
Birth Date*

MonthDayYear
Home Phone:*
Social Security Number:*
Local Contact:*
Employer:*
Employer's Address 1:*
Employer's Address 2:
City:*
State:*
Zip Code:*
Business Phone:*
Do you Maintain Full Coverage Insurance?

YesNo
Renter's Insurance Company:
If No is selected above, I acknowledge I do not maintain full coverage insurance on a vehicle. I acknowledge the Collision Damage Waiver (CDW) at the rate of $15.95 for each day. Acceptance of the CDW limits renters liability for damages to the rental vehicle up to $500.00. Any violations of this agreement makes renter fully liable for damage to vehicle even if renter has paid for CDW. CDW is not insurance.

I Agree
I decline the Collision Damage Waiver (CDW) and accept full responsibility for all damages to the rented vehicle.

I Decline
Customer Responsibility:

1. Customer is responsible for returning vehicle.
2. Customer is responsible for tire repairs.
3. Customer is responsible for vehicle fluids. Rental does not include gas or oil.
4. Customer must notify rental company of all accidents immediately.
5. Customer must return car in clean condition or a charge will be assessed.
6. Customer pays for insurance related Rental.
7. Customer is responsible for all towing and related charges.
Comments:
Should be Empty: