Fillable Collision Damage Claim Form Claims Submission Checklist 3 (Trip Preserver online claims)

Fill Online, Printable, Fillable, Blank Collision Damage Claim Form Claims Submission Checklist 3 (Trip Preserver online claims) Form

Use Fill to complete blank online TRIP PRESERVER ONLINE CLAIMS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Collision Damage Claim Form Claims Submission Checklist 3 (Trip Preserver online claims)

On average this form takes 15 minutes to complete

The Collision Damage Claim Form Claims Submission Checklist 3 (Trip Preserver online claims) form is 2 pages long and contains:

  • 1 signature
  • 12 check-boxes
  • 49 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Trip Preserver online claims forms online.

BROWSE TRIP PRESERVER ONLINE CLAIMS FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Collision Damage
Claim Form
Claims Submission Checklist
To avoid delays in processnig your claim, you must provide the following information.
3 Answer all questions on both pages of this form.
3 Provide a copy of the following documents:
• Initial and nal auto rental agreement(s)
• Repair estimate or itemized repair bill
• Two photographs of the damaged vehicle, if avialable
• Copy of police report
• Damage report submitted to your rental company
• Copy of credit card statement used to rent the vehicle
• Copy of driver’s license
• Proof of payment of auto repairs
3 Mail the completed form along with all documentation to the address shown above.
To be completed by Insured / Guest
Name of Insured / Guest DOB (mm/dd/yy) Plan / Policy #
Address of Insured / Guest Home Phone # Alternative Phone #
Insured / Guest’s E-mail Address
Trip Departure Date Trip Return Date
Name of Person Driving Rental Vehicle Is this person listed on the
Rental Agreement?
Date of Loss Time of Loss Exact Location (City, State, Country)
Name of Rental Company Name of Rental Company Contact
Address of Rental Company Rental Company Phone #
Rental Vehicle Year, Make and Model
Do you have any other insurance that may provide coverage for this claim (auto, travel
insurance, credit card? If yes, please provide company name, phone #, and policy #.
Name of driver’s auto insurance company, policy # and phone #
Were the police notied?
If yes, please provide the police department and phone number.
Was an accident report made with the rental company?
If not, please le a report immediately.
Name of leaseholder on the rental property
List all guests occupying the property.
Arch-2014
Yes
No
AM
PM
Yes
No
Yes No
Yes No
Claims Department:
Red Sky Claims, C/O Arch Insurance Company
Executive Plaza IV, 11350 McCormick Road, Suite 102, Hunt Valley, MD 21031 United States
Toll Free Phone: (844) 800-2486 | Fax: (443) 279-2901 | E-mail: redsky@archinsurance.com
Any person who knowingly presents a false or fraudulent claim for payment of loss or benet or
knowingly presents false information in an application for insurance is guilty of a crime and may be
subject to nes and connement in prison.
Collision Damage
Claim Form
Claims Department:
Red Sky Claims, C/O Arch Insurance Company
Executive Plaza IV, 11350 McCormick Road, Suite 102, Hunt Valley, MD 21031 United States
Toll Free Phone: (844) 800-2486 | Fax: (443) 279-2901 | E-mail: redsky@archinsurance.com
Any person who knowingly presents a false or fraudulent claim for payment of loss or benet or
knowingly presents false information in an application for insurance is guilty of a crime and may be
subject to nes and connement in prison.
Describe below how the damage
occurred to the vehicle.
Diagram of Accident
In the Diagram show the exact relationship of roadways and vehicles at the time of the
accident. Mark all other vehicles as #2, #3, etc. Please indicate North with an arrow.
Who do you think was at fault for the accident? Was any cited by the police? If yes, who?
Witness/ Passenger Information
(a) Name of Witness / Passenger Address Phone #
(b) Name of Witness / Passenger Address Phone #
(c) Name of Witness / Passenger Address Phone #
Other Drivers Involved
Vehicle #2 Driver’s Name Address Phone #
Insurance Company Policy # Reported?
Vehicle #3 Driver’s Name Address Phone #
Insurance Company Policy # Reported?
Any person who knowingly and with intent to injure, defraud or deceive any insurance company, les a statement of claim containing any false,
incomplete, or misleading information may be guilty of a criminal act punishable by law. I have read the foregoing, and the above answers are
true and complete according to the best of my knowledge and belief.
Signature of Insured / Guest Date
Trip Preserver Product is Underwritten by Arch Insurance Company.
Arch-2014
Yes No
Yes No
Yes No
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Collision Damage Claim Form Claims Submission Checklist 3 (Trip Preserver online claims)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 12 September 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document