Gap Insurance Claim
GAP Insurance Claim
Claimant Information
|
Name |
[Your Name] |
|---|---|
|
Address |
123 Main Street, Anytown, USA |
|
Phone Number |
(123) 456-7890 |
|
|
[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]
