ACCIDENT ACCIDENT FORM

ACCIDENT FORM

TELEPHONE

Roadside Assistance (Dedicated Desk)

0120-80-6324

Celeb rent a car

0120-859-337

ACCIDENT REPORT

If an accident occurs, please remain calm and take the following steps.
1.If anyone is injured,Call 119 and administer first aid.
2.Provide first aid to the injured and move the vehicle to a safe location to implement safety measures.
3.Please contact the police at 110.
(Even for minor accidents or single-vehicle accidents, you must contact the police. If you do not report the accident to the police, we may be unable to pay the mutual aid benefits.)

If the input is correct, please press the Submit button.

Circumstances of the accident

RequiredYour name
RequiredDate and time of accident occurrence  /   /   /   / 
RequiredLocation of the accident

The other party's situation

RequiredDriver's Name
RequiredDriver's phone number
Driver's Address
RequiredRental Car Company Name

*If the other party is not a rental car, please enter an appropriate character.

Contact information for the rental car company
RequiredInsurance Company Name
Insurance Company Contact Information
Vehicle Type and License Plate Number

Condition of damaged items(property damage)

Broken items

Accident scene images

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images2 ×
images3 ×

Map of the location where the accident occurred

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images2 ×
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