GAP Insurance Claim
Claimant Information
Name | [Your Name] |
|---|
Address | 123 Main Street, Anytown, USA |
|---|
Phone Number | (123) 456-7890 |
|---|
Email | [Your Email] |
|---|
Vehicle Information
Make | Honda |
|---|
Model | Civic |
|---|
Year | 2050 |
|---|
VIN | 1HGCM82633A123456 |
|---|
Incident Details
Date of Theft: January 1, 2053
Location of Theft: 456 Elm Street, Anytown, USA
Description of Incident: On January 1, 2053, at approximately 10:00 PM, I discovered that my vehicle was missing from its parked location outside my residence. I immediately reported the theft to the local police department. I reported the theft of my vehicle, but the police have not found it yet.
Insurance Information
Primary Insurance Company | ABC Insurance |
|---|
Policy Number | 123456789 |
|---|
Claim Number | 987654321 |
|---|
Policy Coverage Amount | $15,000 |
|---|
Documents Attached
Police report
Primary insurance claim documentation
Original vehicle purchase agreement
Recent loan statement
Photograph of the vehicle
Statement of Loss
The actual cash value (ACV) of the vehicle, as determined by the primary insurer, is $12,000. The remaining balance on the loan at the time of theft was $18,000, which resulted in a gap amount of $6,000. I am submitting this claim to cover the outstanding amount not covered by my primary insurance.
Declaration and Signature
I declare that the information provided in this claim form is true and accurate to the best of my knowledge. I understand that any false statements or misrepresentations may result in the denial of my claim or other legal consequences.
[Your Name]
[Date]
Insurance Claim Templates @ Template.net
