Fillable Rental Vehicle Insurance Excess Waiver Form printable pdf download

Travel Insurance Claim Form

Rental Vehicle Insurance Excess Waiver

You must register any claim within 30 days of completion of your travel. Please supply original documents of the evidence you intend to rely on for

your claim, and send by registered post to ensure delivery.

Claimant Details

Claim Reference

(if known)

Title (Mr / Mrs etc)

First Name

Surname

Date of Birth

Nationality

Occupation

Home Address

Home Phone

Work Phone

Mobile

State

Postcode

Policy Details

Policy Number

Date Issued

Number of Travellers

Independent Travel Arrangements:

Yes

If no, provide the following*:

*Travel Agent and Branch

*Tour Operator

Date of Booking

Departure Date

Return Date

Total Days

Country

Resort / Town

I DECLARE THAT:

Company Limited in its absolute discretion considers relevant for its assessment of initial or

ongoing benefits for my claim including, without limitation:

I will use my best endeavours and render all reasonable assistance and co-operation to

Auto & General Insurance Company Limited in the assessment of my claim:

a ll medical, surgical or other information concerning myself, my medical history, any treatment

received by me and any medication taken or prescribed for me (at any time);

T he information supplied by me is true and correct and I have not withheld any

information likely to affect the assessment of my claim;

m y Health Insurance claims history, including Medicare;

I understand that the claim may be denied if the information supplied is untrue, or I

a ny information in relation to my assets, liabilities, earnings, salary or wages (at any time);

have not revealed all relevant facts;

a ny information from third persons who may have information relevant to my eligibility to

I understand that by investigating my claim or by accepting proofs of my claim, Auto &

receive benefit, or my entitlement to receive an ongoing benefit.

General Insurance Company Limited has made no acceptance of liability, nor waived

Privacy Statement

any of its rights in defence of any claim arising under the policy;

The personal and sensitive information collected in this form, and other information you or third

A photocopy of this Authorisation shall be considered as effective and valid as the

parties provide in connection with this claim will be held, used and disclosed by us to process

original and I specifically authorise its use as such.

this claim, compile and analyse data, and resolve claim disputes.

I appoint Auto & General Insurance Company Limited to do everything necessary or

We may have to disclose your personal and other information to third parties who assist us in

expedient to:

assessing and processing this claim, including other insurers, health providers, investigators, our

g ive effect to the transactions contemplated by the authorisations described; and

specialist advisors, service providers, or as required by law. Your personal information may also be

e xecute and deliver any other documents or do any other acts referred to in the

disclosed to third parties in the countries and regions nominated under your policy, or any other

transactions described.

regions where you may require assistance. For further information please see our privacy policy

I authorise any person, corporation, institution, private or government organisation,

or email us at .au.

whether named by me or not, to provide such information as Auto & General Insurance

If you wish to give authority for another person to act on your behalf in respect to this claim you must complete the following details (otherwise we will not

be able to give any information about your claim to any other person).

I / We, authorise (Name)

of (Address)

Postcode

Phone

Mobile

Date of Birth

I have read and fully understand the declarations above (ALL persons claiming must sign)

Claimant’s Name

Signature

Date of Birth

Date

Claimant’s Name

Signature

Date of Birth

Date

Please return this claim form to:

Budget Direct Travel Insurance, Locked Bag 3038

Rental Vehicle Insurance Excess Waiver Form

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