Rental Vehicle - Collision/loss And Personal Effects Claim Form (Page 6 of 6) in pdf

Rental Vehicle - Collision/loss And Personal Effects Claim Form Page 6

SECTION 9: IMPORTANT, PLEASE READ AND SIGN

CERTIFICATION: The undersigned hereby certifies that the information provided by him or her on this form and otherwise

in support of this claim is complete and accurate to the best of each of his or her knowledge and belief. In the event of a

false or misleading statement in the making of this claim, coverage can be void, payment of this claim denied and any

claim payments made in error recovered. The undersigned agrees to refund the amount of any payments that should not

have been made.

PERSONAL INFORMATION NOTICE: The information provided with respect to this claim is required by the insurer

and its authorized administrator, Allianz Global Assistance, and any insurance adjuster appointed to investigate any

losses on its behalf (collectively “we” “us” “our”) for insurance purposes, such as to assess any entitlement to benefits

and to administer this claim. We will investigate and administer this claim by consulting the insurer’s existing files and

by exchanging additional information with the undersigned and third parties, such as law enforcement, fire and

emergency services departments, parties involved with any subrogation action, and other independent sources. ALL

REQUIRED INSURANCE, POLICE, CLAIM FORMS AND REPORTS MUST BE PROVIDED TO US BEFORE YOUR

CLAIM CAN BE PROCESSED.

Primary Cardholder/Subscriber (please print) ________________________________

Signature of Primary Cardholder/ Subscriber: _______________________________ Date signed:___________________

(MM/DD/YY)

CLAIM MUST BE FILED WITHIN 90 DAYS OF INCIDENT.

Completed and signed claim forms and supporting documents should be returned to Allianz Global Assistance within

90 days from the date of incident. Prompt attention to this request for information is required to adjudicate your claim.

Please note that photocopies and scanned images are acceptable. However, it is your responsibility to keep the

originals for one year after payment as we reserve the right to audit and ask for the originals to be sent to us during

that time.

Should you choose to submit original documents they will not be returned upon completion of your claim.

Rental Vehicle - Collision/loss And Personal Effects Claim Form Page 6