RENTAL VEHICLES
ONLY
LIABILITY POLICY NUMBER
PHPR
PHYSICAL DAMAGE POLICY NUMBER
PHEX
ACCOUNT NUMBER
LIMITS
OF
LIABILITY
BODILY
INJURY
PER PERSON
COVERAGE IS
A
FFORDED AS
SPECIFIED IN
THE POLICY
LISTED ABO
VE
COLLISION
DEDUCTIBLE
PER OCCURRENCE
PROPERTY DAMAGE
COMPREHENSIVE
DEDUCTIBLE
EXCESS
NAME AND
COMPLETE
ADDRESS OF
NAMED
INSURED
M
AIL THIS FORM TO:
ATTN: Customer Service/Policy Administration
ADD/ DELETE
PHILADELPHIA INSURANCE COMPANIES
ONE BALA PLAZA, STE 100
BALA CYNWYD, PA 19004
On-Line Add/ Delete Form www.phly.com
Email form to: Autorental@phly.com
OR FAX TO: (866) 566-0329 OR call (877) 438-7459
THIS TRANSACTION SHALL TAKE EFFECT AT 12:01 A.M. STANDARD TIME AT THE ADDRESS OF THE NAMED INSURED AS STATED HEREIN,
PROVIDED, HOWEVER, IF THE NAMED INSURED SHALL FORWARD COPIES HEREOF TO THE COMPANY WITHIN 10 DAYS AFTER NAMED
INSURED SHALL TAKE POSSESSION OF THE VEHICLE. COVERAGE SHALL BECOME EFFECTIVE AT 12:01 A.M. STANDARD TIME, THE DATE
RECEIVED AT THE COMPANY.
ALL VEHICLES ON THIS FORM TO BE
ADDED OR DELETED AS INDICATED IN THE
BOX. DO NOT ADD AND DELETE ON THE
SAME FORM.
ADD
DELETE
SIGNATURE DATE
EFFECTIVE
DATE
UNIT
NUMBER
YEAR MAKE MODEL SERIAL NUMBER TRUCK (GVW
)
STATED
VALUE
INSURANCE INFORMATION FORM
Add Delete Form - Auto Daily Rental
© 2017 Philadelphia Consolidated Holding Corp.
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