Rental Vehicle - Collision/loss And Personal Effects Claim Form Page 5
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6SECTION 6: INFORMATION REGARDING OTHER VEHICLE(S) INVOLVED IN THE ACCIDENT
Automobile Owner __________________________________________________________________________________
Home Phone (
) ____________________ Address ______________________________________________________
Insurance Company Name ________________________________________ Telephone # (
) ___________________
Address: _____________________________City_______________ Prov./State ________ Postal/Zip Code___________
Insurance Policy # __________________________________
Claim # ____________________________________
Contact Name _______________________________________ Automobile Licence Plate _______________________
Automobile Make, Model, Year ___________________________Province/State of Registration _____________________
If vehicle Owner was not the driver, please provide
Name of driver __________________________________________________
Address _________________________City ___________________Prov. /State ____________ Postal/Zip Code _______
SECTION 7: LEGAL IMPORTANT (please print)
Yes
No
Do you intend to seek, or have you sought legal advice regarding this matter?
Yes
No
Do you intend to litigate this matter?
Have you commenced any settlement negotiations with a third party or their insurer regarding this accident? Yes No
Please note: If you have answered yes to any of the above questions, please advise Allianz Global Assistance
immediately.
Lawyer’s Name (if appointed) ___________________________ Law Firm Name ______________________________
File No. ______________________Telephone # (
) ___________________ Fax # (
)_________________
Address________________________________________________________________________________________
(Street)
(Apt)
(City/Town)
_________________________________________________________________________________________________
(Province/State)
(Postal/Zip Code)
SECTION 8: CLAIM SUMMARY
Amount of this claim $ _________ Currency ______ Amount paid by other insurance (if any) $ ________ Currency _____
Employer
Benefits are payable to (check one)
Attention of ___________________________________
Employer Address ___________________________________________________________________________
Cardholder
Rental Company
Other ___________________________________________________
NOTE: You are required to file a claim with any insurance company that may cover this occurrence. If you have
done so and are awaiting a response, please attach a copy of that claim to this form.
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