COLLISION/LOSS AND PERSONAL EFFECTS CLAIM FORM

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1 RENTAL VEHICLE COLLISION/LOSS AND PERSONAL EFFECTS CLAIM FORM YOUR CLAIM MUST BE FILED WITHIN 90 DAYS OF INCIDENT. Step 1: Step 2: Complete and sign the attached claim form. Please provide the following documentation, if applicable, and check the appropriate box for each item included: Copy of your credit card statement showing the final rental charges. Copy of the original opened and closed car rental agreement (front and back) including rental agency Terms and Conditions. Copy of the car rental company s Accident Loss/Damage Report Form. Copy of the final itemized repair bill. A copy of the driver s license of the person who was driving the car. Receipts for any repairs, which you may have already paid, if applicable. A photograph(s) of the damaged vehicle and/or item(s), if applicable. Police report and police incident number and report from other appropriate authorities for collision and damaged/stolen items. If claiming for loss-of-use, a copy of the rental agency s daily utilization log from the date the car was not available for rental to the date the car became available to rent. If claiming for Personal Effects, please also include the following: Photocopy of your personal insurance declaration page showing deductible. A copy of the final disposition of any claim(s) you submitted to any other insurance company (including documentation of any declined claims). Copy of the original itemized receipt for items claimed FREQUENTLY ASKED QUESTIONS: 1. Why do I have to report my accident to the police? Most rental agreements and jurisdictions require that you report your accident. If the police will not visit the accident site due to lack of injury or damage, collision reporting centres can supply you with an accident report. 2. What if I am told I cannot obtain a police report but my insurance company can? In most cases you will be able to access a copy of the police report unless the investigation of the accident is not completed or the report itself is not completed. We can request this report if you are having difficulty obtaining it however the cost will be deducted from your claim as it is an ineligible expense. In most cases it is cheaper for the insured to obtain the report.

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3 Return Claim Form and Documents to: Allianz Global Assistance P.O. Box 277 Waterloo, ON N2J 4A4 Fax: (Check one) I am claiming for: Personal Effects COLLISION/LOSS AND PERSONAL EFFECTS CLAIM FORM Collision/Loss Damage Please print unless otherwise indicated SECTION 1: ACCOUNT INFORMATION Mr Mrs Ms Miss Name: Street: Case # (if applicable): Date of Birth (MM/DD/YY): City: Province: Postal Code: Home Phone: Business Phone: ( ) Was the full cost of the rental charged to your credit card? Yes No Policy Number (if credit card number please only list last four digits) Name as it appears on this card Date of Birth of this card holder (MM/DD/YY) Issuing Bank: Which card was the purchase made on? Primary Card Secondary Card Did you have a rental agreement prior to or following this rental Yes No (If yes please include the rental agreement) SECTION 2: DESCRIPTION OF INCIDENT Date incident occurred (MM/DD/YY): Place incident occurred: (city/province/state/country) Police report incident #: Did police charge anyone involved in the accident? Yes No Brief description of incident: For personal effects claim: If damaged, can the item be repaired? Yes No (if yes please enclose copy of repair bill/estimate) Is the damage to the item visible? Yes No (if yes please enclose a photograph of the item

4 SECTION 3: DESCRIPTION OF LOST/DAMAGED/STOLEN ITEMS (FOR PERSONAL EFFECTS) Date incident occurred: (MM/DD/YY) Number of persons claiming: Currency MM/DD/YY 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 (MM/DD/YY) Ending (MM/DD/YY) Rental Agreement # Automobile Licence Plate Automobile Make, Model, Year Province/State of Registration Rental Company Telephone # ( SECTION 5: OTHER INSURANCE ) 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 Do you have? Insurance Company Name Policy Number Homeowner/Tenant/Condominium Insurance Yes No Business Liability Insurance Yes No Other Insurance Yes No Have you submitted a claim to any of the above? Yes 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. No

5 SECTION 6: INFORMATION REGARDING OTHER VEHICLE(S) INVOLVED IN THE ACCIDENT Automobile Owner Home Phone ( SECTION 7: LEGAL IMPORTANT (please print) SECTION 8: CLAIM SUMMARY ) 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 Do you intend to seek, or have you sought legal advice regarding this matter? Yes No Do you intend to litigate this matter? Yes No 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) Amount of this claim $ Currency Amount paid by other insurance (if any) $ Currency Benefits are payable to (check one) Employer 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.

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.

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