Fillable GAP Protection Claim FormGP

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GAP Protection Claim FormGP

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  • 24 other fields

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File type: PDF

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To initiate a claim on your covered vehicle, we ask that you please complete the following information to help efficiently
process your claim. In addition to the information below, please be certain to forward all required documentation noted on
the back of your GAP claim contract. For your convenience, we have included a list of all the required documents and how to
obtain them on the Claim Submittal Instructions.
L
ast Name, First Name
r
equired
D
ate of Total Loss
C
urrent Mailing Address
required
Home Phone Cell Phone E-mail
Y
ear/Make/Model
required V
IN (Vehicle Identification Number)
required
FINANCE/LEASING COMPANY
C
ompany Name Account #
A
ddress City State ZIP
Phone
PRIMARY INSURANCE CARRIER
Company Name Adjuster Name Phone
Vehicle Purchased NEW Vehicle Purchased USED Trucks Only — Body Style: Fleetside Sportside
Model Type: ______________________ Mileage/Odometer at Date of Purchase: ________________________________
(e.g., LS, SLT, XE, SLE, etc.)
Other (please list any specialty packages or options not listed above):
Customer Signature Date
You are strongly encouraged to make your scheduled loan payments until your claim is settled.
Please include this form with your required claim documentation as noted in the Claim Submittal
Instructions. Upon receipt of this document, a Claims Associate will contact you to further assist you
with handling your claim. For questions or further assistance, please contact the Claims Department
at 800-890-7211.
GPCLM Rev 7/11
4x4
Air Conditioning
Air Conditioning
(rear)
Aluminum/Alloy Wheels
AM/FM Stereo
Auto Transmission
Bedliner
Bedliner
(spray-on)
CD Player
Cassette Player
Cruise Control
DVD Entertainment System
Fog Lamps
Fiberglass Cap
Heated Seats
Leather Seats
Luggage/Roof Rack
Manual Transmission
Navigation System
Power Door Locks
Power Seat
(Drivers)
Power Seat (Dual)
Power Sliding Doors
Power Steering
Power Sunroof
Power Windows
Removable Hard Top
Running Boards
Satellite Radio
Second Row Bucket Seats
Snow/Plow Package
Specialty Stereo System
(Bose, Infinity)
Spoiler
Theft Deterrent/Alarm
Theft Recovery System
Third Row Seats
Tilt Wheel
Tonneau Cover
Towing/Trailer Package
GAP Protection Claim FormGP
Please fill out the following Options and Information. Please do not include any items added to your vehicle after the time
of purchase. IMPORTANT: including items not on your vehicle, or that were added after the time of purchase may reduce
your final claim amount.
PLEASE FORWARD THE FOLLOWING DOCUMENTATION TO SAFE-GUARD PRODUCTS IN ORDER TO PROCESS
YOUR CLAIM. ANY ONE DOCUMENT WILL START A CLAIM.
Please note, under Claim Requirements on the reverse side of the GAP Deficiency Waiver Addendum: Your claim is time
sensitive. Please refer to your contract regarding the time required to submit your claim documents. Failure to provide the
documentation within the specified timeframe may VOID the protection.
Please send all documentation to:
Mailing Address: Fax Numbers: Email Address:
Safe-Guard Products International, LLC 678-553-1372 claims@sgintl.com
Attn: GAP Claim Department 678-553-1365
Two Concourse Parkway, Suite 500
Atlanta, GA 30328
800-890-7211
For questions or further assistance, please contact the Claims Department at 800-890-7211.
www.safe-guardproducts.com • 8 0 0 . 7 4 2 . 7 8 96
GPCLM Rev 7/11
GAP Protection Claim Submittal InstructionsGP
DOCUMENT
D
ESCRIPTION
O
BTAIN FROM
Insurance Company
Settlement Check
Photocopy or draft copy of the Insurance Company check(s). Insurance Company
Insurance Company
S
ettlement Statement
On Insurance Company letterhead with Adjuster name and
t
elephone number. Includes date of loss, cause of loss, miles at
date of loss, Actual Cash Value, applicable taxes and tag fees,
deductible amount and final settlement figure.
Insurance Company
Insurance Company
Settlement Evaluation
Full Insurance Evaluation Report showing how the insurance
company determined the Actual Cash Value of the vehicle. Must
include any options on the vehicle and mileage at the date of loss.
Insurance Company
Complete Payment
History Record and
Payoff Statement
History of all transactions occurring since inception of loan.
Includes payoff as well as a statement from the lienholder
showing detailed payoff with per diem interest.
Lender
Police Report Full, official Police Report, or “Cause of Loss” letter from insurance
company stating that a police report was not filed and an
explanation regarding the cause of loss.
Police Department or
Insurance Company
GAP Contract Photocopy of GAP Loan/Lease Deficiency Waiver Addendum (front
and back).
Dealership or Lender
Loan/Lease Finance
Agreement
Photocopy of front of Loan Contract or Lease Agreement. Includes
mileage at date of purchase.
Dealership or Lender
Buyer’s Order/
Purchase Order
Photocopy of front of Buyer’s Order/Purchase Order (not
applicable in CA).
Dealership
MSRP
(new vehicles only)
Manufacturer’s suggested retail price located on the window
sticker and the invoice.
Dealership
Completed Claim Form GAP Protection Claim Form Safe-Guard
Proof of Refund Amount
or Expiration of any
Cancelable Items
If a Refund: Copy of the Contract and check copy or statement of
dollar amount of refund on dealer letterhead.
If Expired: Copy of Contract and substantiation of vehicle mileage
(mileage expiration).
Dealership
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GAP Protection Claim FormGP

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Completed 21 January 2021

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