Fillable Bailment Form Or Complete this form to the (Plymouth Rock Assurance)

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Bailment Form Or Complete this form to the (Plymouth Rock Assurance)

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CLAIM NUMBER
(12-digit number)
DRIVER’S AFFIDAVIT
To be completed by the driver of the vehicle involved in the accident.
I was the driver of a which was involved in an accident on / / , with a
vehicle owned by . I borrowed the car from its owner for my own personal purposes.
The owner of the vehicle gave me no instructions regarding operation or route, and I was in no way acting under his/her direction or control
in the use of his/her vehicle.
✘
/ /
Driver’s Signature Date
STATEMENT OF OWNER TO SUPPORT BAILMENT
To be completed by the owner of the vehicle involved in the accident.
I am the owner of a which was involved in a accident on / / . I was not
a passenger in my vehicle at the time of the accident, and I lent my car to for his/her own
personal purposes. I gave him/her no instructions regarding the operation or route, and he/she was in no way acting under my direction or
control in the use of my vehicle.
✘
/ /
Owner’s Signature Date
Year, Make and Model of the Vehicle
Year, Make and Model of Your Vehicle
Name of Driver of Your Vehicle
Name of Driver of Other Vehicle
Date (mm/dd/yyyy)
Date (mm/dd/yyyy)
Bailment Form
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, mail the form to Plymouth Rock’s Claims
Department at the address provided at the bottom 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. Then mail the form to
Plymouth Rock’s Claims Department at the address provided
at the end of the form.
Or
Claims Department
Plymouth Rock Assurance Corporation, PO Box 9112, Boston, MA 02112-9112
Return This
Form To
Thank you.
All Rights Reserved ©2012 Rev_02_12
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.
?
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Bailment Form Or Complete this form to the (Plymouth Rock Assurance)

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Completed 3 August 2021

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