Pump Drive-Off Incident Form & Invoice        

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

Date of accident:__________________ Time:____________ Pump #_______________
Customer Information

Name:___________________________________________________________________

Address:_________________________________________________________________

City:______________________________ State:_________________ Zip:____________

Phone Home:________________________ Phone Work:__________________________

Drivers License #:________________________________________ State:____________

Vehicle License:___________________________________________________________

Vehicle Make:__________________Color:____________ Model __________Year:_____

 
Insurance Information

Insurance Company:___________________________________________________________

Phone Number:______________________ Policy Number:_____________________________

 
Invoice

Breakaway $____________________

Labor          $____________________

Sales Tax    $____________________

Total            $____________________

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:__________________________