Fillable Afdavit of Vehicle Fire (Plymouth Rock Assurance)

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Afdavit of Vehicle Fire (Plymouth Rock Assurance)

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The Afdavit of Vehicle Fire (Plymouth Rock Assurance) form is 3 pages long and contains:

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  • 25 check-boxes
  • 201 other fields

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File type: PDF

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Affidavit of Vehicle Fire
CLAIM NUMBER
(12-digit number)
PERSONAL INFORMATION
First Name of Insured: Last Name of Insured:
Date of Birth: / / Social Security Number: – – Driver’s License Number:
Street Address: City: State: Zip Code:
Home Phone: ( ) – Work Phone: ( ) – Cell Phone: ( ) –
Employer: Occupation:
DETAILS ABOUT THE FIRE
Date of Fire: / / Time of Fire: :
¡
am
¡
pm Was the vehicle locked?
¡
Yes
¡
No
Were keys left in the vehicle?
¡
Yes
¡
No Specific Location of Fire:
Information about the Person Who Left the Vehicle at this Location
First Name: Last Name: Driver’s License Number:
Street Address: City: State: Zip Code:
Home Phone: ( ) – Work Phone: ( ) – Cell Phone: ( ) –
Information about Other People Present at the Fire
1
First Name: Last Name:
Street Address: City: State: Zip Code:
2
First Name: Last Name:
Street Address: City: State: Zip Code:
Information about Discovery of the Fire
Date of Discovery: / / Time of Discovery: :
¡
am
¡
pm
Discovered by Whom: (First & Last Name)
Information about Reporting the Fire to the Police and Fire Departments
Date Report Filed: / / Time Report Filed: :
¡
am
¡
pm
To complete this form by hand:
1 Print all pages of the form.
2 Complete the form by filling in each space with black or blue
ink. Do not use pencil.
3 When finished, have your signature notarized before mailing
the form to Plymouth Rock’s Claims Department at the
address provided at the end of the form.
To complete this form electronically:
1 Save this writable PDF to your computer, then open it using
Adobe’s Acrobat Reader.
2 Complete the form by typing in each field and/or checking
the appropriate buttons. Tip: you can tab from field to field.
3 When finished, save and print the form and have your signature
notarized before mailing the form to Plymouth Rock’s Claims
Department at the address provided at the end of the form.
Or
Form continues
Complete this form to the best of your knowledge and belief. DO NOT GUESS at any answers. If you don’t know the
answer to a question, leave that field blank. Please call your Claim Representative if you need help.
?
Person Who Filed Report: (First & Last Name)
Officer Who Took Report: (First & Last Name)
Street Address of Fire Department: Fire Dept. Case Number:
IF STOLEN, Information about Recovery of the Vehicle
Date of Recovery: / / Time of Recovery: :
¡
am
¡
pm
Specific Location of Recovery:
VEHICLE INFORMATION
Make: Model: Body Type: Year:
Exterior Color: Interior Color: Engine: (e.g., 4-cylinder, V6, V8)
Vehicle Identification Number: License Plate Number: State:
Mileage Reading: (Approximate if unknown)
Condition of the Vehicle Before the Fire (Please specify “Good,” “Fair,” or “Excellent”.)
Paint: Transmission: Engine: Body:
Vehicle Equipment (Please check if your vehicle had any of the following.)
¡
AM/FM Radio
¡
CD Player
¡
CD Changer
¡
USB Audio Interface
¡
Power Windows
¡
Tinted Glass
¡
Sunroof
¡
Moon Roof
¡
Power Seats
¡
Air Conditioning
¡
Air Bags
¡
Anti-Theft Device
¡
Alloy Wheels
¡
Premium Wheels
¡
Custom Wheels
¡
Vinyl Roof
¡
Automatic Transmission
¡
Manual Transmission
¡
Power Brakes
¡
Anti-Lock Brakes
¡
Power Steering
¡
Tilt Wheel
¡
Cell Phone: (Provide number) ( ) –
¡
Other: (Please specify)
¡
Other: (Please specify)
Other Distinguishing Features (e.g., Dents, Decals, Trailer Hitch, Accessories, etc.)
Purchase Information
Date of Purchase: / /
¡
New
¡
Used Purchase Price: $
Vehicle Purchased from:
¡
Dealer
¡
Individual Vehicle Paid for By:
¡
Cash
¡
Check
¡
Financing
Trade-In Car?
¡
Yes
¡
No IF YES, Make: Allowance for Trade: $
Dealer Name OR Individual’s First Name: Individual’s Last Name:
Street Address: City: State: Zip Code:
Financing Information (Please complete this section if your vehicle was financed.)
Finance Company: Account Number:
Street Address: City: State: Zip code:
Balance Due: $ Monthly Payment: $ Term of Loan: (Number of Months)
Date of Your Last Loan Payment: / /
Is your account past due?
¡
Yes
¡
No IF YES, how long past due? (Number of Months)
Affidavit of Vehicle Fire (continued)
Form continues
Affidavit of Vehicle Fire (continued)
Form continues
Maintenance Information
Date of Last Service: / / Name of Repair Shop/Garage:
Street Address: City: State: Zip Code:
Station/Garage Who Performed the State Safety Inspection
Date of Last Inspection: / / Name of Station/Garage:
Street Address: City: State: Zip Code:
Prior Vehicle Damage and Insurance Information
Was the vehicle damaged during the past 3 years?
¡
Yes
¡
No IF YES, describe damage below. (Location, Type, Amount, and Date)
Location:
Type:
Amount: Date: / /
Were the damages repaired?
¡
Yes
¡
No
¡
Partial IF YES, by whom? (Shop Name)
Street Address: City: State: Zip Code:
IF CLAIM WAS MADE, Insurance Company Who Paid Damage Claim:
Street Address: City: State: Zip Code:
Have you had any other claims in the past 3 years on this or any other vehicle?
¡
Yes
¡
No
Do you have any other vehicles in your household?
¡
Yes
¡
No
Insurance Company and Agency on Other Vehicles:
Prior Insurance Company: Prior Agent:
Are the keys in your possession?
¡
Yes
¡
No
Is this vehicle also insured under another automobile insurance policy?
¡
Yes
¡
No
IF YES, Insurance Company: Policy Number:
Are the answers you have given true to the best of your knowledge and belief?
¡
Yes
¡
No
✘
Policyholder Signature (To be signed in the presence of a Notary Public.) Print Name
✘
Witness Signature Print Name
Witness Street Address: City: State: Zip Code:
Claims Department
Plymouth Rock Assurance Corporation, PO Box 9112, Boston, MA 02112-9112
Return This
Form To
Thank you.
Affidavit of Vehicle Fire (continued)
All Rights Reserved ©2012 Rev_02_12
YOUR SIGNATURE MUST BE NOTARIZED.
Please bring this form to a Notary Public. Sign on the line above in their presence and have your signature notarized.
State of: County of:
On this day of , 201 , before me, the undersigned notary public, personally appeared
, proved to me through satisfactory evidence of identity, being in this
instance , and acknowledged to me that he/she signed the foregoing
voluntarily and for its stated purpose.
Notary Public Signature:
✘
My Commission Expires: / /
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Afdavit of Vehicle Fire (Plymouth Rock Assurance)

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Completed 3 August 2021

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