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