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Claims Form
Claimant:
(Required)
What type of claim is this?
(Required)
Damage to vehicle - cosmetic
Damage to vehicle - mechanical
Damage to personal property
Missing personal property
Other
Registered owner of vehicle:
(Required)
Year, make & model of vehicle repossessed:
Vehicle Identification Number
(Required)
What is your home address?
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Best contact phone number:
Email
Date of Statement:
MM slash DD slash YYYY
Date of Repossession
MM slash DD slash YYYY
Did you witness the repossession take place?
Yes
No
What time did it occur?
Hours
:
Minutes
AM
PM
AM/PM
Did you see the damage done? If yes, Describe the circumstances related to the damage occurring.
Did you speak to the repossessor?
Yes
No
Did you surrender the keys to the vehicle?
Yes
No
Can you describe the equipment used to repossess the vehicle?
Was the vehicle towed from the front or the rear?
Towed from Front
Towed from End
Was the vehicle parked rear end in or head in?
Rear end in
Head in
Describe the weather at that time?
Where was the vehicle parked at the time of repossession?
Has the vehicle been previously involved in any accident?
Yes
No
If yes. When?
MM slash DD slash YYYY
Describe any previous damage.
Who was the last person to drive the vehicle?
Before discovering the damage, when was the last time you saw the car?
Date
MM slash DD slash YYYY
Time
Hours
:
Minutes
AM
PM
AM/PM
Was the car locked last time you saw it
Yes
No
If yes, did you park the car where it was repossessed from?
Where did you redeem your vehicle?
Date
MM slash DD slash YYYY
Time
Hours
:
Minutes
AM
PM
AM/PM
Please describe the damage in detail.
Was there any aftermarket equipment installed on the vehicle?
Was there a police report made?
Yes
No
If yes, provide the Police contact information, report number and officers name.
Have you obtained an estimate for the alleged damages?
Yes
No
If yes, attach a copy.
Max. file size: 300 MB.
Are there any pictures available of the vehicle or the incident?
Yes
No
If yes, attach a copy.
Max. file size: 300 MB.
Are you aware of any video of the incident?
Yes
No
If yes, attach below. Or if too large please submit video clips to claims@driveparamount.com and put the date of the incident, Vin number if any in the subject line, reference your name in the email.
Max. file size: 300 MB.
Were there any witnesses to this claim?
Yes
No
If yes, Please provide us with name and contact information.
What proof do you have to show that the damage wasn’t there before the vehicle was repossessed?
Attach supporting documents.
Max. file size: 300 MB.
Do you have full coverage insurance on the vehicle?
Yes
No
If yes, what company and policy number?
Please list all items that you are claiming as damaged and their estimated value at the time of the loss (factor in estimated wear and tear). If you are providing replacement costs, you must note: ITEM DESCRIPTION, ESTIMATED REPLACEMENT COST, DATE ORIGINALLY PURCHASED
Please Read:
(Required)
I understand that my signature below certifies, under penalty of perjury, that the information submitted by me is true and correct.
(Required)
I understand that any false or misleading information submitted by me will result in a denial of this claim and possible criminal prosecution, under state law for insurance fraud.
(Required)
Attach a legible copy of your State issued identification or your claim will not be considered. Your failure to cooperate will result in a denial of your claim.
(Required)
Your cooperation with the claims handler during our investigation is necessary to properly evaluate your claim. Your lack of cooperation may result in a denial of your claim.
(Required)
Our investigation, which may consist of, but not limited to, interviewing witnesses and individuals who may have any knowledge of the issues described by you. This may include, but is not limited to, your neighbors, repair shops, your lender, the original selling dealer, and others we determine to be relevant t the claim submitted.
(Required)
By electronically executing this claim form, I am declaring, under penalty of perjury, that the information contained herein is true and correct. I understand that the submission of false information is a crime and may result in the filing of a criminal complaint to the local law enforcement and a request for criminal prosecution and/or punishment.
(Required)
I understand that my signature below certifies, under penalty of perjury, that the information submitted by me is true and correct.
Signature
(Required)
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