Upload
david-ewen
View
215
Download
2
Embed Size (px)
DESCRIPTION
Car Rental Receipt While Civic Being Repaired Police Report http://tinyurl.com/12-2905-AC Incident Photos http://tinyurl.com/Allstate70Appleton
Citation preview
Reimburse For Car Renhl From Allstate
David Ewen
BB Appleton St.
Springfield, MA 01108
r See Allstate Clairn # $258T81699r See Hanover Claim # 14929703
David Ewen paid $7O1.89 for car rental while car repaired frqnr 9/14 -> 10/5
o Rental Co: Enterprise (CAMRAC, LCCJ
o 765 East Columbus Ave, Springfield, MA (413) 739-2344
Rental Agreement 52796I
Ref # 3MR3BB
Police Report httpr/ /tin5rurl.com/12-2905-AC
In cid ent Photos http= / /tinyurl.com/AllstateT0Applefqn
fEnclosed: Receipt and Police Report]
CAMRAC, LLC, 765 E COLUMBUS AVE, SPRINGFIELD, trtA 011052542 (413) 7gg-2344
1 RENTAL
22 DAY
Page 1 of 1
Rate Total28.25 62 1.50
$0.00WAIVED
6.25o/o $4L.29
$0.60 $0.60
$ 1.7s $38. s0
RENTAL AGREEMENT52796L
RENTEREWEN, DAVID
ADDITIONAL DRIVEREWEN, MARIA
DATE & TIME OUT09/ L4/2AL2 11 :01 AMDATE & TIME INL0/A5/20t2 02:L2 PM
BILLING CYCLECALENDAR DAY
Taxes & SurchargesMASSACHUSETTS STATE SALES
Og/L4 -TAXPARKTNG TTCKET SURCHARGE 091L4 -VEHICLE LICENSE COSTRECOVERY ' O9/L4.
REF#3MR3BB
SUMMARY OF CHARGES
Charge Description Date uantiTIME & DISTANCE a9/L4 - 10/05 22REFUELING CHARGE 09/L4 - 10/0sYOUNG DRIVER FEE 18 -99 09/L4 - 10/05
10/0s
10/0s
10/0s
VEH #T 2912 CHEV MALI 1LT4VIN# 1G LZCSEO6CF3 66L72LIC# 699PA4MILES DRIVEN 1OO9
CLAIM TNFOSHOP: BALISE COLL REPAIR CNTR-SPFLD*XATTN: UNKNOWN
Total Amount Due
PAYMENT INFORMATION
$o.oo
AMOUNT PAID$701.89
TYPEVisa
CREDIT CARD NUMBERXXXXXXXXXXXXO2S3 PEN DING
I
70 l,tq
Subtotal:
Total Cha
r0l5l20r2
Date of Crash
09/Lt/20L2Time of Crash
14 1024HR
City/Town
SPRINGE IELDSpeed Linft 3 0 State Police tr
Local Police trMBTA Police trOther:
AT INTERSECTION: NOT AT II{TERSECTION:
R"rt.# Dit.rt-t
Direction Name of Roadwaylstreet
-jktrRoute# Direction Name of lntersectine Roadwav/Street
i t r Also at Intersection with
Csq+*o* ffiSw #s",{*r &tg-"/',51:
r..t lfTITi-lFl or . orMile Marker Exit Number
Address # Name of Roadway/Street
r.., [fTEfillFl og
p..1 [fTETillFl og
Intersecting Roadway'Street
[l v.nicle t 1 #occupants l-l ui,rnun L2-2905-ACn!g* 1ww750 Regrvpe Pc RegstateffiTilveh year 19 93 veh Make cHEvRoLET veh config. lgl i,l
Vehicle Action Prior to Crash
Drivercontributingcode ffiEInunderride/override ffi Towed 2
Vehicle Travel Direction, IFXJ-E fwl Responding to Emer gency? 2 Event Sequence
Citation # (If rssuea; R2 8 8 5 14 1
Viol. 1: ch/sec/Sub 90 /10 viol. 2: Ch/Sec/Sub
Viol. 3: Ch/Sec/Sub I Viol.4: Ch/Sec/Sub
License+ S81193622 stl"tA DoB/Age 07 /29/]-973
Sex F Lic classtr-L1 Lic Restrictionsff pol,*-.*operator ORTIZ
' SYLVIA L
Address 70 APPLETON ST
SPRINGFIELD s 01108 - 2902
Insurance Company
owner ORTIZ, SYLVfA L
SPRINGFIELD state MA zip O]-LOS-2902
Damaged Area Code: (Circle Up to Three)
Most Harmful Event
4
0 None
E 10 Undercarriagef, l l rotaled97 Other
6 99 Unknown
Name (.ast ror, *oo,rrtlease fill out for operator and all occupants tnvolved
Medical Facilitv
BAYSTATEMEDICAI
[l v.rricle 20 #occupants fxoo-MotoristAType'ffiActionffiLocationffiConditionHfl f-l uirnoo
St- DOB/Age
operator Driverless M. V.
city SPRINGFtrELD
Insurance Company CITIZENS Vehicle Action Prior to Crash
Vehicle Travel Direction, [NXf;lwl Responlurg to Emer gency? 2 Event Sequence
Citation # (If Issued)
Viol. 1: Ch/Sec/Sub
Viol. 3: ChlSec/Sub
Viol.2: Ch/Sec/Sub
Viol.4: Ch/Sec/Sub
l-' iolveh year 2 012 veh Make HOIIDA veh Conrig. 11 ,., 1
@nn Unknown
o.oo.. E!{EN ' DAVID-IL
Address 88 APPLETON ST
State M[ zip
t.,.,)1 )J )1
0 None
- l0 Undercarria) l l rotaled97 OtherDriver contributing code [38
Underride/override ilE To*.d 2 8
Please fill out for operator/non-motorist and all occupants involvedName Q-ast First Middle) Address
27SafetySystem Medical Facility
Op erator/\Ion-Mot o ri st
Commonwealth of MassachusettsMotor Vehicle Crash
Police Report
+>= Direction E - vehicle I f;l= vehicle 2ff = Pedestrian
-)Rie: +r, I ->trl
l{/V *L S on Aplleton St by #90 when coJ-lision occured. Oper #1 :nlrgt3t'egy at scene,suffering fron pre-existing medical condition prior to condition and transported toBaystate Nedical via AI{R 4t6.
Appjtrstsft, "5,1 IIi$T T#.SilALE
12-a.qil5-Af;
If Crash Did NotOccuron a Public Way:
il Off-street Parking Lot
n Garage
tr MaUshopping Center
tr Other Private Way
@North
l4/V #2 Parked, unoccupied in front of 90 Appleton St when coJ.J-ision occured.
Name (Last,First,Middle) Phone # Statement
Owner (Last,First,Middle) Phone # Description of Damaged Properfy
Registration # (From Vehicle Section)
Carrier Issuing Authority Code
US DOT #: State Number
Trailer Ree #: Reg \pe Reg State Reg Year Trailer Lenqth
Hazmat Information:
Material 4 diEt #+elease code
gFq+ce,.r EDMRD N HINEY H49 0el11l2012Police Officer Name @lease Print) Signature ID/Badge # Department Precincttsanacks Date
cDPl 11-2{-00