Loaner Vehicle Agreement
Please complete this form to document the temporary loan of a vehicle. All information is required for agreement and accountability.
Borrower's Full Name
*
First Name
Last Name
Borrower's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Borrower's Email Address
*
example@example.com
Owner's Full Name
*
First Name
Last Name
Vehicle Make and Model
*
Vehicle Year
*
Vehicle Identification Number (VIN)
*
License Plate Number
*
Loan Start Date and Time
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Loan End Date and Time
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Purpose of Vehicle Loan
*
Current Vehicle Condition
*
No visible damage
Minor scratches
Dents
Warning lights on dashboard
Other (please specify below)
If you selected 'Other' for vehicle condition, please describe:
Insurance Coverage Confirmation
*
Yes, the vehicle is insured
No, the vehicle is not insured
Odometer Reading at Start (miles or km)
*
Odometer Reading at End (miles or km, if known)
Deposit Method (if applicable)
*
Cash
Credit Card (last 4 digits only)
No deposit required
If deposit is by credit card, enter last 4 digits
Borrower's Signature
*
Submit Agreement
Submit Agreement
Should be Empty: