DOCUMENTS REQUIRED FOR GAP CLAIM

DATE FILED__ CONTRACT #_

NAME ON POLICY___________________________________________________

CURRENT ADDRESS_________________________________________________

CITY__________________________ STATE_______ ZIP___________________

PHONE (h)_____________________ (w)_______________________

PURCHASED FROM__________________________________________________

YEAR_________ MAKE____________ MODEL_________________________

CUSTOMER

q Police Report Page #_______

q CCC Valuation/Adjusters Report Page #_______

q Statement of Total Loss Page #_______

q Insurance Declaration Page Page #_______

q Insurance Settlement Check Page #_______

q Payoff Amount as of Date of Loss Page #_______

q Payment History Page #_______

q Copy of GAP Policy (front & back) Page #_______

q Finance Contract – Original Vehicle Page #_______

q Finance Contract – Replacement Veh. Page #_______

q Invoice . Page #_______

q Buyers Order Page #_______

CANCELLATION AMOUNTS (stated on Dealer Letterhead)

q Service Contract $________ q Credit Life $__________ q Credit Disability $_______

COMPLETED BY____________________________________

DATE FAXED_____________________

COMMENTS_______________________________________________________