Address: 649 Southlawn Lane Suite A, Rockville, Maryland, 20850, US
Telephone: 3017622195

Forms

Step 1 of 3 - Vehicle & Driver

Vehicle Out Date*
Date Format: MM slash DD slash YYYY
Select Vehicle
Select the name of the vehicle provided by your service advisor from the dropdown menu.
Select Loaner*
Primary Driver
Full Name*
Email*
Phone Number*
Drivers License Number*
Expires*
Date Format: MM slash DD slash YYYY
Photo of Driver's License*
Date of Birth*
Date Format: MM slash DD slash YYYY
Insurance Company*
Policy Number*
Photo of Insurance Card*
Would you like to add second driver?
- Yes
- No

Secondary Driver
Full Name
Email
Phone Number
Drivers License Number
Expires
Date Format: MM slash DD slash YYYY
Photo of Driver's License*
Date of Birth
Date Format: MM slash DD slash YYYY
Insurance Company
Policy Number
Photo of Insurance Card*

ALL LOANERS are SMOKE FREE and PET FREE
1. The Recipient’s Insurance Coverage is primary and will be responsible for any and all damage and liability arising out of or in any way related to the use and operation of this Loaner Vehicle.
2. The Recipient will be responsible for any and all deductibles and expenses not covered by his/her insurance at the time of accident or incident.
3. THE RECIPIENT IS AT LEAST 25 YEARS OF AGE AND HOLDS A VALID DRIVER’S LICENSE.
4. I hereby entirely assume sole and absolute responsibility and liability for any damage to the vehicle described above and owned by Total Recon Auto Center and for any and all damages including pet hair and dander, loss, expense, fee and/or claim resulting from or relating to the operation of said vehicle while it is in my possession or under my control.
5. I have motor vehicle liability insurance coverage which complies with the State of Maryland minimum liability requirements and is sufficient to provide primary first vehicular coverage against any and all losses, damages, expense, fee and/or claim and hereby agree to indemnify and hold Total Recon Auto Center harmless from and against any and all losses, claims, damages, expenses and/or fees, including attorney’s fees, related to my possession of said vehicle while it is in my possession or under my control. Total Recon Auto Center’s insurance is excess over any other collectible insurance.
6. I shall pay a penalty of $ 50.00 (fifty dollars) PER CALENDAR DAY that I keep the Loaner Vehicle after Total Recon Auto Center has advised me in person, via telephone call, voicemail, email or text message, that service on my vehicle has been completed or an estimate for the recommended repairs have been provided. Total Recon Auto Center will allow me 24 hours to make a decision when I have received the estimate before a penalty will be assessed.
7. I agree to pay any parking and /or toll violation fees that are assigned to the vehicle when in my possession as well as a $ 25.00 research and processing fee.
8. In the event of an incident, I agree to be responsible for loss of use in the amount of $50.00 per day.
9. I agree to return the vehicle with the same fuel level as I received it. Failure to do so will result in a $20 REFUEL FEE and will be billed at $3/gallon.
Consent*
I Agree to the terms listed above
Signature*
By signing here, I agree to the Terms & Conditions listed.
Date
Date Format: MM slash DD slash YYYY

Forms

Step 1 of 3 - Vehicle & Driver

Select Vehicle

Primary Driver

Secondary Driver