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

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

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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 statemetn 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
Toll Free Phone: (866) 889-7409 | 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
Toll Free Phone: (866) 889-7409 | 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
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signature
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The laws of some states require us to furnish you with the following notices:
WARNING. Any person who knowingly:
Alaska: and with intent to injure, defraud, or deceive an insurance company les a claim containing false, incomplete, or misleading information
may be prosecuted under state law.
Arizona, Arkansas and Rhode Island: presents a false or fraudulent claim for payment of a loss or benet is subject to criminal and civil pen-
alties, or specic to AR and RI: presents false information in an application for insurance is guilty of a crime and may be subject to nes and
connement in prison.
California: For your protection California law requires the following to appear on this form:
Any person who knowingly presents false or fraudulent claim for payment of a loss is guilty of a crime and may be subject to nes and conne-
ment in state prison.
Delaware: and with intent to injure, defraud or deceive an insurer, les a statement of claim containing any false, incomplete or misleading infor-
mation is guilty of a felony.
District of Columbia: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other
person. Penalties include imprisonment and/or nes. In addition, an insurer may deny insurance benets if false information materially related to
a claim was provided by the applicant.
Florida: and with intent to injure, defraud, or deceive any insurance company, les a statement of claim containing any false, incomplete, or
misleading information is guilty of a felony of the third degree.
Idaho and Indiana: and with intent to defraud or deceive any insurance company, les a statement of claim containing any false, incomplete or
misleading information (for Idaho) is guilty of and (for Indiana) commits a felony.
Kentucky, New York, and Pennsylvania: and with intent to defraud any insurance company or other person les an application for insurance,
or les a statement of claim, containing any materially false information or conceals, for the purpose of misleading, information concerning any
material fact thereto commits a fraudulent insurance act, which is a crime, specic to PA: subjects such person to criminal and civil penalties and
specic to NY: shall also be subject to a civil penalty not to exceed ve thousand dollars and the stated value of the claim for each such violation.
Louisiana, New Mexico, Texas and West Virginia: presents a false or fraudulent claim for the payment of a loss (or specic to LA, TX and WV: who
knowingly presents false information on an application for insurance) is guilty of a crime and may be subject to nes and connement in state
prison, (or specic to NM: to civil nes and criminal penalties.)
Maryland: and willfully presents a false or fraudulent claim for payment of loss or benet or who knowingly and willfully presents false informa-
tion in an application for insurance is guilty of a crime and may be subject to nes and connement in prison.
New Jersey: les a statement of claim containing any false or misleading information is subject to criminal and civil penalties.
Ohio: with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits and application or les a claim containing a false
or deceptive statement is guilty of insurance fraud.
Oklahoma: and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any
false, incomplete or misleading information is guilty of a felony.
Oregon: and with intent to defraud any insurance company or other person les an application for insurance or a statement of claim containing
any materially false information or conceals for the purpose of misleading, information concerning any fact material hereto, may be subject to
prosecution for insurance fraud.
Puerto Rico: and with the intention of defrauding presents false information in an insurance application, or presents, helps, or causes the pre-
sentation of a fraudulent claim for the payment of a loss or any other benet, or presents more than one claim for the same damage or loss, shall
incur a felony and, upon conviction, shall be sanctioned for each violation with the penalty of a ne of not less that ve thousand (5,000) dollars
and not more than ten thousand (10,000) dollars, or a xed term of imprisonment for three (3) years, or both penalties. If aggravating circum-
stances are present, the penalty thus established may be increased to a maximum of ve (5) years; if extenuating circumstances are present, it
may be reduced to a minimum of two (2) years.
WARNING:
Colorado: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of
defrauding or attempting to defraud the company. Penalties may include imprisonment, nes, denial of insurance and civil damages. Any insur-
ance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyhold-
er or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable
form insurance proceeds shall be reported to the Colorado Division of Insurance withing the Department of Regulatory Agencies.
Hawaii: Presenting a fraudulent claim for payment of a loss or benet is a crime punishable by nes or imprisonment, or both.
Maine/Washington: It is a crime to knowingly provide false, incomplete or misleading information ton an insurance company for the purpose of
defrauding the company. Penalties may include imprisonment, nes or a denial of insurance benets.
Minnesota: A person who les a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.
New Hampshire: Any person who, with the purpose to injure, defraud or deceive any insurance company, les a statement of claim containing
any false, incomplete or misleading information is subject to prosecution and punishment for insurance fraud, as provided in RSA 638.20.
Tennessee and Virginia: It is a crime to knowingly provide false, incomplete or misleading information to an insurer or insurance company for
the purpose of defrauding the insurer or insurance company. Penalties include imprisonment, nes and denial of insurance benets.
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Collision Damage Claim Form Claims Submission Checklist (Trip Preserver online claims)

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Completed 12 September 2021

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