Bonzah Insurance Initial Claim Form

Bonzah Insurance Initial Claim Form

Please complete this form for timely insurance claims service.
If you have just had an accident and someone is injured or there is a road hazard, please call 911.
Anyone who was party to the accident may use this form. This may include the purchaser of the Bonzah policy, the rental car company, employees of other insurance companies, and people who were hit or damaged by the rental car driver. It will be most efficient if the purchaser of the Bonzah policy initiates the claim process, but, nonetheless, any party to the accident may do so. You may designate your role in the accident in the "Preparer" section of this form.
You may start a claim now, save, and submit the claim later. At the end of this form, there will be an option to save. After saving, you will be able to return to this form, add additional information, and do one claim submission. More than one submission may delay your claims process. It is in the renter's best interest to complete this form as thoroughly as possible. Feel free to read the entire form and return to complete when you are ready. You have up to 30 days from the date of the accident/incident to file a claim. Some of the items that you should have for final submission are:

Description of Claim/Accident/Incident (REQUIRED).Photos of the Scene and Vehicle at the Time of the Claim/Accident/Incident (REQUIRED).Signed Copy of Rental Agreement/Contract (REQUIRED).Damage Estimates for Injury to Persons or Damage to Property (REQUIRED).Copy of Policy Report (REQUIRED).Copy of Current Auto Insurance Policy (if applicable).Copy of Credit Card Agreement used for Rental (if applicable).Other Relevant Accident Information (if applicable).
Bonzah Policy Holder Information
Rental Driver's Full Name (Name of the Bonzah Policy Holder)

First NameMiddle NameLast NameSuffix
Rental Driver's Mobile Phone Number (the Bonzah Policy Holder)

Country CodeArea CodePhone Number
Rental Driver's Email Address (the Bonzah Policy Holder)

Confirmation EmailPlease enter the renter's email two times to confirm that it has been entered correctly.
Rental Driver's Home Address (the Bonzah Policy Holder)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Accident Information
Date and Time of Starting to Filling Out this Form*

MonthDayYear
Date
Hour MinutesAM/PM Option
Date and Time of Accident/Loss/Incident*

MonthDayYear
Date
Hour MinutesAM/PM Option
What was the Location of the Accident?
Please Describe the Accident below*
Take your time and add specifics such as names and contact information of witnesses and other parties to the accident. Please confirm the date, time, city and state, in addition to the specifics of what happened. Were there any other vehicles involved? Include the make, model & license #. Include the driver's name, address, phone & email, if available. Any damage to the vehicles? Any passengers in rental vehicle or any other vehicle involved? Include name, address, phone & email, if available. Any witnesses? Include name, address, phone & email, if available. Was anyone injured?
Who Witnessed this Accident?
Please provide their names and contact information.
Were there Other Vehicles involved?
Please describe the vehicles and their drivers and occupants. Include contact information.
Upload Images of the Accident Site, Rental Vehicle and Accident Damage below*

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Upload a copy of the Bonzah Certificates of Insurance / Coverage Forms

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Upload Repair Estimates below

Please include three estimates
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Upload a copy of the Police Report below

Important: A police report is required for the submission of a claim. If the police department refuses to respond to a call to the accident site, you still may be able to obtain a police report by visiting the police department or by completing a police report online.
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Upload a copy of the Current Personal Auto Insurance Policy below

Renter's and Driver's, if applicable
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Upload a copy of the Credit Card Agreement Used for Rental below

If applicable
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What else should we know?
Please add any relevant information here
Upload additional information below

Please upload any relevant information here
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Rental Agency Information for the Bonzah Insured Renter
Rental Agency Name (Name of Rental Company for Bonzah Insured Renter
Rental Agency Agreement or Reservation Number
Number on Rental Contract and/or Supplied by the Rental Agency
Rental Agency Phone Number

Country CodeArea CodePhone Number
Rental Agency Email Address
Upload a copy of the Rental Contract below

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What is the car's year?
What is the car's make or brand?
What is the car's model?
What is the car's license plate?
State and number
Additional Driver Information for the Vehicle Insured by Bonzah

If the Driver of the vehicle insured by Bonzah at the time of the accident (additional driver) was different from the primary Renter on the Rental Contract, please complete the following.
Additional Driver's Full Name (Driver of the Vehicle Insured by Bonzah at the time of the accident)

First NameMiddle NameLast NameSuffix
Additional Driver's Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Additional Driver's Phone Number

Country CodeArea CodePhone Number
Additional Driver's Email Address
Claim Form Preparer's Information

If the Preparer of this Claim Form is different from the Renter or Driver, please complete the following. This is often a party to the accident or an insurance representative.
Claim Form Preparer's Full Name

First NameMiddle NameLast NameSuffix
What is the Perparer's Role in Accident?
A Bonzah policy holder hit you, you work for an insurance company, you work for the Renter, etc.
Preparer's Company Name
If applicable
Preparer's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preparer's Phone Number

Country CodeArea CodePhone Number
Preparer's Email
I, the Preparer of this claim form, have included:*

Description of Claim/Accident/Incident.Photos of the Scene and Vehicle at the Time of the Claim/Accident/Incident.Signed Copy of Rental Agreement/Contract.Damage Estimates for Injury to Persons or Damage to Property.Copy of Policy Report.Copy of Current Auto Insurance Policy (if applicable).Copy of Credit Card Agreement used for Rental (if applicable).Other Relevant Accident Information (if applicable).
I, the Preparer of this claim form, declare that*

All of the information supplied on this claim form is complete, true, and accurate.This claim is made in accordance with the insurance policy.I authorize Bonzah and Bonzah's assignees to obtain from any person or organization any further information required to evaluate this claim.
Signature of Preparer*

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Should you have questions or additional information, please email us at claims@bonzah.com
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Bonzah Insurance Initial Claim Form

If you have just had an accident and someone is injured or there is a road hazard, please call 911.

Bonzah Policy Holder Information

Accident Information

Rental Agency Information for the Bonzah Insured Renter

Additional Driver Information for the Vehicle Insured by Bonzah

Claim Form Preparer's Information