Rental Vehicle - Collision/loss And Personal Effects Claim Form Page 4
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6SECTION 3: DESCRIPTION OF LOST/DAMAGED/STOLEN ITEMS (FOR PERSONAL EFFECTS)
Date incident occurred:
___________________ Number of persons claiming: _____________
(MM/DD/YY)
Currency
MM/DD/YY
Item:____________________________ Purchase price (incl. tax) $_______________ Purchase Date: _______________
Item:____________________________ Purchase price (incl. tax) $_______________ Purchase Date: _______________
Item:____________________________ Purchase price (incl. tax) $_______________ Purchase Date: _______________
Item:____________________________ Purchase price (incl. tax) $_______________ Purchase Date: _______________
Item:____________________________ Purchase price (incl. tax) $_______________ Purchase Date: _______________
Item:____________________________ Purchase price (incl. tax) $_______________ Purchase Date: _______________
Item:____________________________ Purchase price (incl. tax) $_______________ Purchase Date: _______________
NOTE: Your maximum recovery under Collision/Loss and Personal Effects cannot exceed the coverage limit set
in your policy. Depreciation will be applied.
SECTION 4: RENTAL INFORMATION
Auto Rental Period
______________ Ending
_____________Rental Agreement #_______________
(MM/DD/YY)
(MM/DD/YY)
Automobile Licence Plate ________________ Automobile Make, Model, Year __________________________________
Province/State of Registration ___________________
Rental Company ____________________________________________Telephone # (
) _____________________
Address ________________________________City___________________ Prov. _________ Postal/Zip Code________
Driver of rental car at the time of incident, if other than Cardholder ____________________________________________
Driver’s and/or Employer’s Insurance Company (if using corporate card)_________________ Policy # ________________
Address
_________________________________________________________________________________________________
(Street)
(Apt)
(City/Town)
_________________________________________________________________________________________________
(Province/State)
(Postal/Zip Code)
Amount paid by other insurance (if any) $ _______________Currency _____
Amount of deductible $ ______________ Currency ______
SECTION 5: OTHER INSURANCE
Do you have?
Insurance Company Name
Policy Number
Homeowner/Tenant/Condominium Insurance Yes No
________________________
________________
Yes
No ________________________
Business Liability Insurance
________________
Yes
No
Other Insurance
________________________
________________
Have you submitted a claim to any of the above? Yes
No
NOTE: Since this insurance is SECONDARY (for personal effects) to any other insurance you may have, we
require a copy of the declaration page(s) from your other applicable insurance policies. The declaration page is the
portion of your written policy that provides a summary of your coverage, including any deductibles.
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