HERTZ Insurance Replacement System - Self Pay

* To Create A Reservation, fill in all Mandatory fields and click the Send button below.
**Note: You will be prompted to fill in all Mandatory fields before your Reservation is sent.

Transaction Number: HLE010000000001287151882

MANDATORY

OPTIONAL

Renter

First Name:

Last Name:

What is the best time and phone number to reach the customer?

Best Time:

Best Contact Phone: - - ext.:

Hertz Local Edition

Rental Location:

Change Loc

This is the location that has been selected for Rental. The customer can go to this, or any Hertz Local Edition location to pick up their rental car. Please provide confirmation number to customer.

Rental Information

No Auth Reason:

Rental Class:

This field is used to enter the desired car class that the customer is requesting. It is not an authorization.

Days Authorized:

Repair Type:

Mechanical/Service

Body/Collision

Pickup Date:

Drop Off Date:

Rental Per Day ($):

This field is used to enter the total daily amount that the customer is authorized for. For insured claims, this rate does not include taxes and surcharges. For claimants, taxes and surcharges are included.

Max Pay ($):

This field is used to enter the Maximum Payment for the total bill.

Rental Per Day ($):

This field is used to enter the rate amount for the desired car class selected.

Percent Pay:

Auth Per Day ($):

This is calculated Rental Rate Per Day * Percent Pay.

Pay All Taxes:

Renter

Secondary Phone:

- - ext:

Additional Phone:

- - ext:

Date of Birth:

Policy #Policy #:

Repair Order #:

Claim

Claim Number:

Company Insurance:

Providing your Insurance or body shop company name and claim or PO number will ensure that you receive company specific rates and benefits at time of rental.

Message

Please use this field to indicate any additional or pertinent information to Hertz. i.e. Child Seats, Handicap Controls, color preference, special instructions.

Email Confirmation

Send a copy of the reservation to the renter

Email Address: