Car Rental Form

Pa&Nj Car Rental, LLc

• Company Information:

  Select Naheem Smith Naheem61292@gmail.com 267-504-0859 Zion James Jzion559@gmail.com 267-904-7662

  • Naheem Smith Naheem61292@gmail.com 267-504-0859
  • Zion James Jzion559@gmail.com 267-904-7662

• Pa&Nj Car Rental, LLc Manager #:

  Emp937788- Zion J.

  Emp387788- Naheem S.

• Car Rental VIN:

  Select Vin: 2FMDK4KC8ABA30921-2010- Ford Edge Limited AWD. Vin: 1G1ZF5SU1JF218765- (2018- Chevy Malibu Hybrid) Vin: 1G11D5SL7FF261637- (2015- Chevy Malibu Lt.) Vin: 2C3CCAAG9EH377536- (2014- Chrysler 300 basic.) Vin: 5NPE24AF4HH493190- (2017- Hyundai Sonata Basic) Vin: 5XXGT4L34LG430944- (2020- Kia Optima) Vin: 4T1G11AK4RU912827- (2024- Toyota Camry.)

  • Vin: 2FMDK4KC8ABA30921-2010- Ford Edge Limited AWD.
  • Vin: 1G1ZF5SU1JF218765- (2018- Chevy Malibu Hybrid)
  • Vin: 1G11D5SL7FF261637- (2015- Chevy Malibu Lt.)
  • Vin: 2C3CCAAG9EH377536- (2014- Chrysler 300 basic.)
  • Vin: 5NPE24AF4HH493190- (2017- Hyundai Sonata Basic)
  • Vin: 5XXGT4L34LG430944- (2020- Kia Optima)
  • Vin: 4T1G11AK4RU912827- (2024- Toyota Camry.)

• Plate Number:

  Select MNL-4931-Pennsylvania Plate (Ford Edge) E64-UNG -New Jersey Plate (Toyota Camry) MNL-4928 -Pennsylvania Plate (Chrysler 300) MKN-7873 -Pennsylvania Plate (Chevy Malibu18) N94-UMT -New Jersey Plate (Hyundai Sonata) J64-SNY -New Jersey Plate ( Kia Optima) xxx-xxxx - Pennsylvania Plate(Chevy Malibu15)

  • MNL-4931-Pennsylvania Plate (Ford Edge)
  • E64-UNG -New Jersey Plate (Toyota Camry)
  • MNL-4928 -Pennsylvania Plate (Chrysler 300)
  • MKN-7873 -Pennsylvania Plate (Chevy Malibu18)
  • N94-UMT -New Jersey Plate (Hyundai Sonata)
  • J64-SNY -New Jersey Plate ( Kia Optima)
  • xxx-xxxx - Pennsylvania Plate(Chevy Malibu15)

• Make/Model:

  Select Chevrolet-Malibu Hyundai-Sonata Chrysler-300 Kia-Optimal Ford-Edge Toyota-Camry

  • Chevrolet-Malibu
  • Hyundai-Sonata
  • Chrysler-300
  • Kia-Optimal
  • Ford-Edge
  • Toyota-Camry

• Year of Vehicle:

  Select 2010 2014 2015 2017 2018 2020 2024

  • 2010
  • 2014
  • 2015
  • 2017
  • 2018
  • 2020
  • 2024

• Pickup Date:

  Date

• Prepared by:

  Zion, James

  Naheem, Smith
• Location:
  Address

General

• Customer Name:

• Address:
  Address

• Driver's License Number:

• State:

  Select Pennsylvania New Jersey New York Delaware Maryland West Virginia

  • Pennsylvania
  • New Jersey
  • New York
  • Delaware
  • Maryland
  • West Virginia

• Expires:

  Date

• Take a photo of License: (Front)

  Media

• Take a photo of License: (Back)

  Media

• Birthday:

  Date

• Telephone:

• E-mail:

• Date Out:

  Date

• Date of return:

  Date

• Mileage on car now:

• Mileage in the gas tank:

Vehicle

• Renting By Day or Week:

  Day/Daily

  Week/Weekly

• Car Rental Rate Daily or Weeky: (Insurance is mandatory)

  Select $77.00USD per day with insurance and $1000.00USD deductible if accident is cost and renter is fully responsible $92.00 USD per day with insurance and $1000.00USD deductible if accident is cost and renter is fully responsible $300.00USD per week with insurance and $1000.00USD deductible if accident is cost and renter is fully responsible $400.00USD per week with insurance and $1000.00USD deductible if accident is cost and renter is fully responsible $500.00USD per week with insurance and $1000.00USD deductible if accident is cost and renter is fully responsible $600.00USD per week with insurance and $1000.00USD deductible if accident is cost and renter is fully responsible $77.00USD per day and an additional $500.00USD for lost and damage fee. ($577.00USD must pay In-full.) Lost damage is half of the deductible which is $1000.00USD. Zero Dollars is due if any accidents happen under ur responsibility. $97.00USD per day and an additional $500.00USD for lost and damage fee. ($597.00USD must pay In-full.) Lost damage is half of the deductible which is $1000.00USD. Zero Dollars is due if any accidents happen under ur responsibility. $300.00USD per day and an additional $500.00USD for lost and damage fee. ($800.00USD must pay In-full.) Lost damage is half of the deductible which is $1000.00USD. Zero Dollars is due if any accidents happen under ur responsibility. $400.00USD per week and an additional $500.00USD for lost and damage fee. ($900.00USD must pay In-full.) Lost damage is half of the deductible which is $1000.00USD. Zero Dollars is due if any accidents happen under ur responsibility. $500.00USD per week and an additional $500.00USD for lost and damage fee. ($1000.00USD must pay In-full.) Lost damage is half of the deductible which is $1000.00USD Zero Dollars is due if any accidents happen under ur responsibility. $600.00USD per week and an additional $500.00USD for lost and damage fee. ($1100.00USD must pay In-full.) Lost damage is half of the deductible which is $1000.00USD Zero Dollars is due if any accidents happen under ur responsibility.

  • $77.00USD per day with insurance and $1000.00USD deductible if accident is cost and renter is fully responsible
  • $92.00 USD per day with insurance and $1000.00USD deductible if accident is cost and renter is fully responsible
  • $300.00USD per week with insurance and $1000.00USD deductible if accident is cost and renter is fully responsible
  • $400.00USD per week with insurance and $1000.00USD deductible if accident is cost and renter is fully responsible
  • $500.00USD per week with insurance and $1000.00USD deductible if accident is cost and renter is fully responsible
  • $600.00USD per week with insurance and $1000.00USD deductible if accident is cost and renter is fully responsible
  • $77.00USD per day and an additional $500.00USD for lost and damage fee. ($577.00USD must pay In-full.) Lost damage is half of the deductible which is $1000.00USD. Zero Dollars is due if any accidents happen under ur responsibility.
  • $97.00USD per day and an additional $500.00USD for lost and damage fee. ($597.00USD must pay In-full.) Lost damage is half of the deductible which is $1000.00USD. Zero Dollars is due if any accidents happen under ur responsibility.
  • $300.00USD per day and an additional $500.00USD for lost and damage fee. ($800.00USD must pay In-full.) Lost damage is half of the deductible which is $1000.00USD. Zero Dollars is due if any accidents happen under ur responsibility.
  • $400.00USD per week and an additional $500.00USD for lost and damage fee. ($900.00USD must pay In-full.) Lost damage is half of the deductible which is $1000.00USD. Zero Dollars is due if any accidents happen under ur responsibility.
  • $500.00USD per week and an additional $500.00USD for lost and damage fee. ($1000.00USD must pay In-full.) Lost damage is half of the deductible which is $1000.00USD Zero Dollars is due if any accidents happen under ur responsibility.
  • $600.00USD per week and an additional $500.00USD for lost and damage fee. ($1100.00USD must pay In-full.) Lost damage is half of the deductible which is $1000.00USD Zero Dollars is due if any accidents happen under ur responsibility.

• Gas Tank Reading:

  Full

  3/4

  1/2

  1/4

  Empty

• Miles Allowed :

  100 miles per day

  150 miles per day

  Unlimited miles

Car Insurance

• Insurance Type:

  Progressive

  Good2go

  Dollar-A-Day

• -ISSUING COMPANY Omni Insurance Company EFFECTIVE DATE - Expiration Date 07/02/2024- 12/06/2024 NOT VALID MORE THAN 1 YEAR FROM EFFECTIVE DATE. Omni Insurance Company 2018 Powers Ferry road Atlanta, GA 30339 Or -COMPANY NUMBER: 997 New Jersey Automobile Insurance Plan 10000 Midlantic Drive Suite 403 West Mt. Laurel, New Jersey 08054 (800) 652-2471 (PRODUCER: AFFORDABLE INS AGENCY LLC, 250 N WOODBURY RD LICENSE NUMBER: 1517414 (856) 854-5665 PITMAN, NJ 08071) Or -Progressive 134 Progressive Garden State Ins Co 1-800-776-4737 PO Box 31260 Tampa, FL 33631 Effective: 03/11/2024 Expiration: 09/11/2024 Or -Company Code #:096 STATE OF NEW JERSEY INSURANCE IDENTIFICATION CARD Personal Service insurance Company 1400 Union Meeting Road, Suite 250 Blue Bell, PA 19422 Effective: 04/12/2024 Expiration: 10/12/2024:

  Select 2010- Ford Edge Limited AWD Vin: 2FMDK4KC8ABA30921 NAIC #: 39098 Policy #: 8792844 2018- Chevy Malibu Hybrid Vin: 1G1ZF5SU1JF218765 NAIC #: 39098 Policy #: 8792844 2015- Chevy Malibu Lt Vin: 1G11D5SL7FF261637 Good2go (Omni Insurance Company) NAIC #: 39098 Policy #: 8792844 2014- Chrysler 300 basic Vin: 2C3CCAAG9EH377536 Good2go (Omni Insurance Company) NAIC #: 39098 Policy #: 8792844 2017- Hyundai Sonata Basic Vin: 5NPE24AF4HH493190 Dollar-A-Day ( New Jersey Automobile Insurance Plan) POLICY #:24192302965-EFFECTIVE:07/10/2024 2019- Kia Optima Vin: 5XXGT4L34LG430944 Progressive NAIC #: 14800 Policy #: 978552442 2024- Toyota Camry Vin: 4T1G11AK4RU912827 POLICY #:8808859 NAIC #:12289 VEHICLE ID NUMUER: 4T1011AK4RU912827 No Insurance plan

  • 2010- Ford Edge Limited AWD Vin: 2FMDK4KC8ABA30921 NAIC #: 39098 Policy #: 8792844
  • 2018- Chevy Malibu Hybrid Vin: 1G1ZF5SU1JF218765 NAIC #: 39098 Policy #: 8792844
  • 2015- Chevy Malibu Lt Vin: 1G11D5SL7FF261637 Good2go (Omni Insurance Company) NAIC #: 39098 Policy #: 8792844
  • 2014- Chrysler 300 basic Vin: 2C3CCAAG9EH377536 Good2go (Omni Insurance Company) NAIC #: 39098 Policy #: 8792844
  • 2017- Hyundai Sonata Basic Vin: 5NPE24AF4HH493190 Dollar-A-Day ( New Jersey Automobile Insurance Plan) POLICY #:24192302965-EFFECTIVE:07/10/2024
  • 2019- Kia Optima Vin: 5XXGT4L34LG430944 Progressive NAIC #: 14800 Policy #: 978552442
  • 2024- Toyota Camry Vin: 4T1G11AK4RU912827 POLICY #:8808859 NAIC #:12289 VEHICLE ID NUMUER: 4T1011AK4RU912827
  • No Insurance plan

Payment

• Vehicle Policy (E-signature picture if done by computer. Need Four signatures picture for each term. Please initial if printed on paper)

  Select As the renter of the car by Pa&NJ Car Rental, agrees to all terms bolow: -I agree to follow all driving state laws in any and all states in side Pennsylvania or outside the state of Pennsylvania. _________ initial here -I agree to have the vehicle back at the agreed time on the contract and i agree if the vehicle isn’t returned past the return time, the renter of the vehicle will have to keep the vehicle for another day and is fully responsible for the one day payment (For the car for another day.) The renter is fully Responsible to make sure car is back on time and fully responsible for the payment of renting at a day/daily cost. (must pay immediately ) _________ Initial here. -I agree if any accident happens under the time frame for this car agreement that I am fully responsible at the cost of $1000.00 for The insurance deductible. _________ Initial here. -I agree to not damage the inside of the vehicle with no burnt marks or holes from smoking in the vehicle, I hereby take full ownership of any burnt marks or holes done to any parts of the interior of the vehicle in the time frame that I have/had ownership of the car, even if friends, family, or any one who may company I the renter, in the vehicle cost any damage from smoking. i hereby agree to pay the $400.00USD due to “smoking or burnt fee” ________ initial here

  • As the renter of the car by Pa&NJ Car Rental, agrees to all terms bolow: -I agree to follow all driving state laws in any and all states in side Pennsylvania or outside the state of Pennsylvania. _________ initial here -I agree to have the vehicle back at the agreed time on the contract and i agree if the vehicle isn’t returned past the return time, the renter of the vehicle will have to keep the vehicle for another day and is fully responsible for the one day payment (For the car for another day.) The renter is fully Responsible to make sure car is back on time and fully responsible for the payment of renting at a day/daily cost. (must pay immediately ) _________ Initial here. -I agree if any accident happens under the time frame for this car agreement that I am fully responsible at the cost of $1000.00 for The insurance deductible. _________ Initial here. -I agree to not damage the inside of the vehicle with no burnt marks or holes from smoking in the vehicle, I hereby take full ownership of any burnt marks or holes done to any parts of the interior of the vehicle in the time frame that I have/had ownership of the car, even if friends, family, or any one who may company I the renter, in the vehicle cost any damage from smoking. i hereby agree to pay the $400.00USD due to “smoking or burnt fee” ________ initial here

• Fuel Policy:

  Free Tank

  Full to Full

  Pre-purchase

  Others

• Additional Driver Fee reason:

  Select None Underage Out of State Traveling Uber/ Lyft or other commercial driving Past due balance

  • None
  • Underage
  • Out of State Traveling
  • Uber/ Lyft or other commercial driving
  • Past due balance

• Additional Drivers fee cost: ($)

• Total Charge:

• Payment Received:

  Cash from hand

  Cash App

  Chime

  Apple pay

  Zelle

• Time of payment from rental

  Date

Sign off

• Car Renter: (Full Name and Signature)

  Sign

• Processed By Manager: (Full Name and Signature)

  Sign