Lender Name:_________________________________________________________________________________________
Account Number:______________________________________________________________Vehicle
Refinanced? Y N
Extended Warranty? Y N (Company Name):________________________(Refund
Amount)$:____________________
Credit Life/Disability? Y N (Company Name):________________________(Refund
Amount)$:____________________
Insurance Information
Date of Loss:_________________________________Ins
Co Settled? Y N ? (Settlement Amount):
$_________________
Type of Loss: [Theft: _______ Recovered?
_____] [Collision: _______ 1 VA? _____] Fire: _______ Flood:
_______ Other:_____
______________________________________________________________________________________________________
Auto Insurance
Company:__________________________________________________
WHO’S INS? Insd or 3rd Party
Insurance
Adjuster:_______________________________________________________
(Notes):
Adjuster’s Phone
Number:__________________________________________________
Claim
#:________________________________________________________________
Who has the
Salvage?____________________________Ins Co or Insured or n/a
RPRTD BY__________________________(Relation to
Insd):________________RPRTD TO:__________________
DATE:___________
Please FAX
to (518.863.6963)
(copies of) 1) Retail Insallment Sales Contract,
2) list of Vehicle Options purchased on the
vehicle 3a) the vehicle’s ACV Evaluation Report,
3b) Breakdown of Settlement, 3c) Damage
Appraisal/Estimate; and 4) (if applicable)
Refund Amounts from the cancellation of the
Service Contract(s) (and/or Credit Life/Disability if
Insured chooses to cancel this policy) through the
Dealership, BUT DON’T CANCEL GAP! (PLEASE send
refunds on the policy(s) TO THE LIEN HOLDER).
Phone & Address if not in our GAP address
book:
