Corporate Travel Insurance Claim Form Page 4
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5Section D. Rental Vehicle Excess Claim
THE FOLLOWING ITEMS MUST BE INCLUDED WITH THIS CLAIM
1. Copy of your Rental Vehicle Agreement.
2. Copy of the Repair Invoice if claim is due to the Rental Vehicle being damaged.
3. Copy of documents showing amount debited to you by Rental Vehicle company for damage/excess.
4. Report made to the Police or other appropriate Authority.
Date and time of accident/incident
/
/
Location of accident/incident
Rental Vehicle company name
Country where the vehicle was rented:
Please state in full, exactly what happened for the claim to arise (if necessary, a diagram may be used to depict the event):
Was the damage due to a collision with another vehicle?
Yes
No
Did police attend the incident?
Yes
No
Was the accident/incident your fault?
Yes
No
Repair costs
Date the damage was paid for
/
/
Excess you were liable to pay
Amount you are claiming for
Have you received compensation from any person or party involved in the accident or incident:
Yes
No
If Yes, please state the amount received
Section E. Other
THE FOLLOWING DOCUMENTS MUST BE INCLUDED WITH THIS CLAIM
Please tell us in as much detail as possible what happened to you in order for you to make this claim. Be as specific as possible, including dates and
amounts paid. If there is not enough room in the space provided, you may continue your description of the events on a separate piece of paper.
Payment Details
Provide your bank details below for a direct credit to your nominated bank account.
Please note we cannot deposit into a credit card account.
If we are required to make a payment on your behalf no payment will be made until we receive payment, from you, of any applicable excess.
Name of Bank
Branch:
Account Holder
Bank
Branch
Account number
Suffix
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