Rental Vehicle Insurance Excess Waiver Form Page 2
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2Travel Insurance Claim Form | Rental Vehicle Insurance Excess Waiver
Rental Details
Rental company name
Address
Phone
Rental car make (e.g Ford)
Model (e.g Falcon)
/
/
/
/
Rental start date
Rental return date
Is your rental vehicle in the list of excluded vehicles (see point number 2 in the General Exclusions of Section H):
Yes
No
If yes, unfortunately you can not make a claim under Section H. If no, please proceed
/
/
Drivers Licence Number
State of issue
Expiry
Class (e.g car, truck)
Any restrictions
Details of Incident
Enclosed Documents Checklist - SEND ORIGINAL DOCUMENTS BUT KEEP COPIES FOR YOUR RECORDS
Original Rental Agreement
Original Receipts and accounts for all expenses incurred
Original bills and invoices
Details of any other insurance
Copy of your driver’s licence
Bank Details
Should Auto & General Insurance Company Limited need to reimburse you we require your bank details.
Name of Account Holder
BSB
Account Number
GST
(for domestic policy claims only)
Are you registered for GST and did you claim a
If yes, what is your input tax credit entitlement percentage:
Yes
No
GST input tax credit on your premium?
(i.e. a full entitlement is 100%)
Please return this claim form to:
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Budget Direct Travel Insurance, Locked Bag 3038
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