Get Priority Tow | Compass Cars - Accident Replacement Vehicles

1. Client Details

Handler*

Referrer Name & Company*

Name*

Prefix First Last

Client Phone Number*

Non-drive?*

Yes

Client Address

Claim Number

Client Email

Vehicle Registration

Vehicle Make

Vehicle Model

Repair Start Date

2. Other Party Details

Other Party Name

Other Party Address

Home Phone Number

Mobile Phone Number

Work Phone Number

Licence Number

Claim Number

3. Other Vehicle Details

Other Vehicle Registration*

Other Vehicle Make

Other Vehicle Model

Explain the Accident

Was there a witness?

Yes

Witness Name

Witness Phone

Did the police attend the accident?

Yes

Police Event Number

Police Station

Has the client been injured in the accident?

Yes

Does the client have a valid debit / credit card? (We need this for security for any infringements or accidents in the hire car.)

Yes

Does the client give us permission to contact the at fault party or at fault party insurance on their behalf to discuss their claim?

Yes

Other Details/Special Requests

4. Compliance Statement

In order for us to organise a replacement vehicle for you, we need some of your details, the at fault party’s details and what happened in the accident. As long as the at-fault party is insured and we can confirm that they were at fault, we will be able to provide you with a hire car while your vehicle is submitted for repair. You are liable for the costs of the hire vehicle though Compass will try to recover your cost from the at-fault party on your behalf. In return, you must co-operate with Compass if asked to do so, which may include giving evidence in legal proceedings initiated by Compass in your name.

Read Compliance Statement to Client

Yes

Delivery Sent

Yes

Uber Home?

Yes

Uber to Depot?

Yes

Uber to Work?

Yes

By submitting this form I confirm that I have obtained consent from all relevant parties to disclose their information to Compass Corp and I acknowledge that Compass Corp is relying on this representation in accepting this application for a replacement vehicle.

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Priority Tow

1. Client Details

2. Other Party Details

3. Other Vehicle Details

4. Compliance Statement

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