Rental Car Collision Claim Form

  Instructions

  • Do not use a public computer (e.g. internet cafe, public library) to complete this form
  • Complete the form with as much information as possible. Required fields are marked with an asterisk (ex: ). Some fields may be required based on your response to other questions.
  • On most modern web browsers, the data you enter will be periodically saved. If you need more time to complete this form, you can return to this computer and web browser later to complete the form. You must return to this computer and web browser to resume your claim form in progress - a different computer or different browser will not have your saved responses.
  • Clearing your browser cache may clear your saved claim form data
  • After completing the form, you will have an opportunity to upload documentation (ex: receipts) to support your claim.
  • Please complete and sign the Renters Collision Insurance Claim Form in full and return it with the documentation noted below
    For all claims, submit:
    • Copies of your travel documents confirming your travel dates and itinerary;
    • Copy of your initial and final rental agreements;
    • Repair estimate or itemized bill for repair of the damage;
    • Proof of payment of the claimed repair expenses – copies of both sides of checks, copies of credit card statements or receipts for cash payments;
    • Two (2) photographs of the damaged vehicle, if available;
    • A copy of the report filed with the local police department;
    • A copy of the damage report submitted to your rental company;
    • A copy of your drivers license;
    • A copy of any payments or settlements made by any responsible party or under any other valid or collectable insurance coverage.

  To be Completed by the Insured/Guest

Hint: Your departure date is the date you expected to leave to begin your trip or vacation. Your return date is the date you expected to have arrived home from your trip or vacation.

  Accident Location

  Accident Details

characters remaining. If you need to add more, please upload the details as a file attachment after the claim has been submitted. Describe how the damage occurred to the vehicle, including who you think was at fault for the accident is required

  Make, Model and Year of Rental Vehicle

  Rental Company

(If not, please file a report immediately.)

  Other Insurance

Other Insurance Company

  Police Department

characters remaining. If you need to add more, please upload the details as a file attachment after the claim has been submitted.

Name & Phone for Police Department

  Witness / Passenger #1

  Witness / Passenger #2

  Other Driver #1

  Other Driver #2

  Instructions

To submit your claim

  • 1. Review the notices below
  • 2. Complete the Electronic Signature Panel beneath the notices to sign this document.
  • 3. After signing, click the Submit Claim button to submit your claim.
  • 4. After submitting your claim, you will have the opportunity to upload documentation related to your claim.
  • If you wish to review the information you have entered, click the Return to Claim button at the bottom of this page.

  Important Notices

Warning Any person who knowingly and with intent to injure, defraud or deceive any insurance company, files a statement 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.

The laws of some states require us to furnish you with the following notices:

  • Alaska: and with intent to injure, defraud, or deceive an insurance company files 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 benefit is subject to criminal and civil penalties, or specific to AR and RI: presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement 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 fines and confinement in state prison.
  • Delaware: and with intent to injure, defraud or deceive an insurer, files a statement of claim containing any false, incomplete or misleading information 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 fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.
  • Florida: and with intent to injure, defraud, or deceive any insurer, files a statement of claim or application 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, files 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 files an application for insurance, or files 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, specific to PA: subjects such person to criminal and civil penalties and specific to NY: shall also be subject to a civil penalty not to exceed five 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 specific to LA, TX and W VA: who knowingly presents false information on an application for insurance) is guilty of a crime and may be subject to fines and confinement in state prison, (or specific to NM: to civil fines and criminal penalties.)
  • Maryland: and willfully presents a false or fraudulent claim for payment of loss or benefit or who knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
  • New Jersey: files 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 an application or files 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 files 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 presentation of a fraudulent claim for the payment of a loss or any other benefit, 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 fine of not less than five thousand (5,000) dollars and not more than ten thousand (10,000) dollars, or a fixed term of imprisonment for three (3) years, or both penalties. If aggravating circumstances are present, the penalty thus established may be increased to a maximum of five (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, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
  • Hawaii: Presenting a fraudulent claim for payment of a loss or benefit is a crime punishable by fines or imprisonment, or both. Maine/Washington: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.
  • Minnesota: A person who files 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 a purpose to injure, defraud or deceive any insurance company, files 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, fines and denial of insurance benefits.

Authorization to Disclose Information

To any medical care provider, medical care facility, insurer, government-sponsored health plan, or employer: I authorize the release of any medical information about me to Arch insurance Company, or it’s authorized representative, Administrative Concepts Inc. This applies to all information about the diagnosis, treatment, or prognosis of any illness or injury I now have or have had in the past.

To any insurance company, any travel organization or agency, airline carrier, cruise line, tour operator, rental agency, hotel, motel, or similar entity providing lodging on a rental / lease basis or any other person who may have knowledge regarding this claim: I authorize the release any information requested regarding this claim and the loss reported.

The company will use this information to determine if any claim is eligible. Any information obtained will not be released by the Company except to my primary health insurance carrier (if any) or persons or organizations performing investigation or legal services for the Company in connection with my claim. A copy of this authorization shall be considered as effect and valid as the original and shall remain in effect for one year from the date of authorization.

I certify that the information given by me in support of my claim is true and correct. I understand that any person who knowingly and with intent to defraud or deceive any insurance company, files a claim containing any materially false, incomplete or misleading information may be subject to prosecution or insurance fraud.

  Electronic Signature

By selecting "I Accept", you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement. By selecting "I Accept" you consent to be legally bound by this Agreement's terms and conditions.

Total Amount Claimed