Rental Car Request Form - Go Rentals

  • What is your first name?
  • What is your last name?
  • What is your email address?
  • What is your phone number?
  • What is the year, make and model of the car that was damaged?
    YearMakeModel
  • What is the name of the body shop where your car is being repaired?
  • What is the name of your contact at the body shop?
  • What is the phone number for the body shop?
  • What is the address of the body shop?
  • Please enter your claim adjuster's name.
  • What is the claim adjusters phone number?
  • What is the claim adjuster's email address?
  • Please enter your claim number, if known.
  • Please enter the coverage amount you have available for a rental car.
  • Documents and Comments

  • Please use this field to upload any relevant documents.
    Drop files here or
    Max. file size: 128 MB, Max. files: 10.
    • Please enter any additional remarks in the space below.

    Virtus Personal Lines Insurance




    We have a heart for people and a genuine passion for helping others -- our clients, partners, colleagues, and the community. We treat each other as family and work collaboratively to get the job done while having some fun along the way. Be prepared with the proper insurance solutions in place. Contact us to discuss protection, we've got your back!


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