Reimburse For Car Renhl From Allstate David Ewen BB Appleton St.
Springfield, MA 01108
r r
See
Allstate Clairn # $258T81699
See Hanover Claim
# 14929703
David Ewen paid $7O1.89 for car rental while car repaired frqnr 9/14 -> 10/5
o o
Rental Co: Enterprise (CAMRAC, LCCJ 765 East Columbus Ave, Springfield,
MA (413) 739-2344
Rental Agreement 52796I Ref # 3MR3BB
Police
Report
In cid ent
httpr/ /tin5rurl.com/12-2905-AC
Photos http= / /tinyurl.com/AllstateT0Applefqn
fEnclosed: Receipt and Police Report]
Page 1 of CAMRAC, LLC, 765 E COLUMBUS AVE, SPRINGFIELD, trtA 011052542 RENTAL AGREEMENT
REF#
52796L
3MR3BB
(413) 7gg-2344
SUMMARY OF CHARGES
RENTER EWEN, DAVID
Charge Description
ADDITIONAL DRIVER
TIME & DISTANCE
EWEN, MARIA
REFUELING CHARGE YOUNG DRIVER FEE
18
Date
uanti
Rate
Total
a9/L4 - 10/05
22
28.25
62 1.50
09/L4 - 10/0s 09/L4 - 10/05
-99
$0.00 WAIVED
DATE & TIME OUT 09/
L4/2AL2
11
:01 AM
DATE & TIME IN
L0/A5/20t2 02:L2
PM
BILLING CYCLE CALENDAR DAY VEH #T 2912 CHEV MALI 1LT4 1G LZCSEO6CF3 66L72 LIC# 699PA4
VIN#
MILES DRIVEN 1OO9
CLAIM TNFO
Subtotal: Taxes & Surcharges MASSACHUSETTS STATE TAX PARKTNG TTCKET
SALES
Og/L4 - 10/0s
SURCHARGE 091L4 - 10/0s
VEHICLE LICENSE COST
'
RECOVERY
O9/L4. 10/0s
1 22
RENTAL DAY
6.25o/o
$4L.29
$0.60 $ 1.7s
$38. s0
$0.60
Total Cha Total Amount Due
$o.oo
PAYMENT INFORMATION TYPE AMOUNT PAID Visa
SHOP: BALISE COLL REPAIR CNTR- $701.89
CREDIT CARD NUMBER XXXXXXXXXXXXO2S3
SPFLD*X ATTN: UNKNOWN
I
70
r0l5l20r2
1
l,tq
PEN
DING
Date of Crash
Time of Crash
09/Lt/20L2 14
10
Commonwealth of Massachusetts Motor Vehicle Crash IELD Police Report
City/Town
SPRINGE 24HR
AT INTERSECTION:
Direction
i
r
License+ Sex
F
Lic
operator Address
S81193622
#occupants
stl"tA
l-l
DoB/Age 07
/29/]-973
1ww750 year 19 93
veh
Regrvpe veh Make
Direction, IFXJ-E
fwl
Viol.
90
/10 fill
Responding to Emer gency? 2
RegstateffiTil veh config.
lgl
i,l
ORTIZ, SYLVfA L
SPRINGFIELD
state
MA
zip
O]-LOS-2902
Damaged Area Code: (Circle Up to Three) 4
Event Sequence
0 None
E 10 Undercarriage f, l l rotaled
Most Harmful Event
Drivercontributingcode
viol. 2: Ch/Sec/Sub
I
Ch/Sec/Sub
Pc
cHEvRoLET
Vehicle Action Prior to Crash
R2 8 8 5 14 1
Name (.ast
Intersecting Roadway'Street og
n!g*
01108 - 2902
s
Citation # (If rssuea;
Viol. 3:
p..1 [fTETillFl
owner
Insurance Company
ch/sec/Sub
Exit Number
ST
SPRINGFIELD
1:
or
L2-2905-AC
SYLVIA L
' 70 APPLETON
Vehicle Travel
.
Marker
r.., [fTEfillFl og
ui,rnun
classtr-L1 Lic Restrictionsff pol,*-.*
ORTIZ
tr tr
Name of Roadway/Street
Mile
Also at Intersection with
v.nicle t 1
Police
Other:
#
Address
Csq+*o* ffiSw #s",{*r &tg-"/',51: R"rt.# Dit.rt-t [l
Police tr
MBTA Police
Name of lntersectine Roadwav/Street
t
State
Local
r..t lfTITi-lFl or
-jktr
30
NOT AT II{TERSECTION:
Name of Roadwaylstreet
Route# Direction
Linft
Speed
underride/override
Viol.4: Ch/Sec/Sub
ffiEIn
6
Towed 2
ffi
97 Other 99 Unknown
out for operator and all occupants tnvolved
ror, *oo,rrtlease
Medical Facilitv
BAYSTATE
MEDICAI
[l
v.rricle
20
#occupants
St-
fxoo-MotoristAType'ffiActionffiLocationffiConditionHfl
DOB/Age veh year
operator
Driverless
M.
V.
city
Vehicle Travel
CITIZENS
Direction,
[NXf;lwl
2
012
HOIIDA DAVID-IL veh Make
o.oo.. E!{EN Address
Insurance Company
' 88 APPLETON
Responlurg to Emer gency?
2
SPRINGFtrELD
Event Sequence
Op
Driver contributing
State
)1
)J
iol ,.,
1
M[
zip
)1
t.,.,
0 None
out for operator/non-motorist and all occupants involved
Middle) erator/\Ion-Mot
Address
o
ri st
code
Underride/override
Viol.4: Ch/Sec/Sub
fill
11
Vehicle Action Prior to Crash
Viol.2: Ch/Sec/Sub
Viol. 3: ChlSec/Sub Please
l-'
Undercarria )- l0 l l rotaled
1: Ch/Sec/Sub
Name Q-ast First
veh Conrig.
ST
Citation # (If Issued)
Viol.
f-l uirnoo
ilE
97 Other
[38 To*.d 27 Safety System
2
8
@nn
Unknown
Medical Facility
+>= Direction E
- vehicle I f;l=
ie: +r, I
vehicle 2
->trl
ff
= Pedestrian
-)R
If Crash Did NotOccur on a Public Way: Appjtrstsft,
IIi$T T# .SilALE
"5,1
12-a.qil5-Af;
il
Off-street Parking Lot
n
Garage
tr
MaUshopping Center
tr
Other Private Way
@ North
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 to Baystate Nedical via AI{R 4t6. l4/V #2 Parked, unoccupied in front of 90 Appleton St when coJ.J-ision occured.
Name (Last,First,Middle)
Phone #
Owner (Last,First,Middle)
Phone #
Registration #
Statement
Description of Damaged Properfy
(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
gFq+ce,.r EDMRD Police Officer Name @lease cDPl 11-2{-00
Print)
N HINEY
Signature
H49#
ID/Badge
#+elease
code
0el11l2012 Department
Precincttsanacks
Date