jlzwhite.gif (125550 bytes) Business Management 
    JLZ Business Services

FORMS.GIF (1618 bytes)

 Our Business Owner's ToolKit Section provides valuable on-line information for today's small business manager. Browse away ... we're certain you'll find information to make your business more successful. 

  Printer friendly version click here.

 printer_icon.jpg (1764 bytes)

Pump Drive-Off Incident Form & Invoice

* To be filled out by cashier at time of damage.

Date of accident:__________________ Time:____________ Pump #_______________
JLZ
 

Customer Information

Name:___________________________________________________________________

Address:_________________________________________________________________

City:______________________________ State:_________________ Zip:____________

Phone Home:________________________ Phone Work:__________________________

Drivers License #:________________________________________ State:____________

Vehicle License:___________________________________________________________

Vehicle Make:__________________Color:____________ Model __________Year:_____

 

JLZ
 

Insurance Information

Insurance Company:___________________________________________________________

Phone Number:______________________ Policy Number:_____________________________

 
JLZ
Invoice

Breakaway $89.95

Labor          $25.00

Sales Tax       7.42

Total         $122.37

Cashier: Indicate how paid:_________________________________

 

I understand that after pumping gas I left the nozzle inserted in the gas tank and started to drive away. I am responsible for the costs to repair the pump which are itemized above. I further understand that I may be responsible for additional hidden damages to the hose, nozzle or dispenser which will be determined after replacing the breakaway.

Signed:_____________________________ Cashier:__________________________