RENTAL REQUEST FORM
(*Required)

First Name:*
Last Name:*
Address:
City:
State: Zip: Phone:
E-Mail:*
Insurance Agency:
Claim Number:
Insurance Claim Phone Number:
Daily insurance allotment (available from your insurance agent):*
$

Pruitt’s Auto Collision will work to provide you immediate auto access with a rental while your car is being repaired. Complete the form and we will contact you or reserve a car for you right away.