SUBMIT A GAP CLAIM

Contact Person at Finance Company/Dealership *

Contact Person Email *

Email

Confirm Email

Contact Person Phone # *

Finance Company or Dealership Name *

Finance Company or Dealership Address *

Address Line 1

Address Line 2

City

State

Zip Code

Customer Name *

Vehicle VIN# *

Date of Total Loss/Theft *

Date of Accident

Was there physical damage insurance on this vehicle or was there an insurance payment on the vehicle? *

Yes
No

Amount of Insurance Payment *

Upload Insurance Settlement/Proof of Payment *

Click or drag files to this area to upload. You can upload up to 6 files.

Complete documentation from the Customer’s primary insurance company or the insurance company paying the claim substantiating the date of and cause of loss of the Vehicle, gross settlement amount, deductible, the net settlement amount and proof of payment

Upload load pictures of the totaled vehicle *

Click or drag files to this area to upload. You can upload up to 8 files.

Upload pictures of the totaled vehicle for proof of loss and helps with valuation of vehicle.

Payoff-Unpaid Net Balance *

As per the Gap Waiver agreement

Upload a Copy Of The Customers Payment Schedule *

Click or drag files to this area to upload. You can upload up to 8 files.

Upload a copy of the customers payment schedule detailing payment frequencies and unpaid net balance.

Upload GAP Waiver *

Click or drag files to this area to upload. You can upload up to 5 files.

Upload a copy of the customer's GAP Waiver

Upload Retail Installment Contract and Buyers Order *

Click or drag files to this area to upload. You can upload up to 5 files.

Upload Police/Accident Report or Impound/Tow bill *

Click or drag files to this area to upload. You can upload up to 10 files.

This provides Proof & Date of loss

Did the customer finance any other products? *

Yes
No

Example: Vehicle Service Contract, Credit Life, and Accident & Health

Upload refundable amounts for all cancelable products

Click or drag files to this area to upload. You can upload up to 10 files.

Documentation showing refund amounts of any cancelable items purchased such as Extended Warranty, Credit Life, and Accident & Health. Please make sure all documents are totally legible.