Rental Vehicle - Collision/loss And Personal Effects Claim Form Page 3
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6Return Claim Form and Documents to:
submit@allianz-assistance.ca
Allianz Global Assistance
P.O. Box 277
Waterloo, ON
COLLISION/LOSS AND PERSONAL
N2J 4A4
Fax: 519-742-9471
EFFECTS CLAIM FORM
(Check one) I am claiming for: Personal Effects
Collision/Loss Damage
Please print unless otherwise indicated
SECTION 1: ACCOUNT INFORMATION
Mr Mrs Ms Miss
Case # (if applicable):
Name:
Date of Birth
:
(MM/DD/YY)
Street:
City:
Province:
Postal Code:
Home Phone:
Business Phone: (
)______________________________
E-mail:
Yes No
Was the full cost of the rental charged to your credit card?
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)
Which card was the purchase made on? Primary Card Secondary Card
Issuing Bank: ______________
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:
Yes
No (if yes please enclose copy of repair bill/estimate)
If damaged, can the item be repaired?
Yes
No (if yes please enclose a photograph of the item
Is the damage to the item visible?
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