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Payless ESP Claim Form 2014-09-23 - HSR) i

Payless ESP Claim Form 2014-09-23 - HSR) i-2025

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48 votes

The document is an Emergency Sickness Protection Claim Form for renters of Payless Car Rental, requiring the renter to provide personal information, medical documentation, and authorization for the insurance company to access medical records. It outlines the necessary steps to submit a claim, including signing the form and attaching relevant documents. Additionally, it includes fraud warnings specific to various states regarding false claims.

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Click ‘Get Form’ to open it in the editor.
Begin by entering your Policy Number at the top of the form. This is essential for processing your claim.
Fill in the Renter’s Report section with your name, phone number, and address. Ensure all details are accurate to avoid delays.
Provide information about the Claimant, including their name, contact number, and address. If applicable, include their Social Security Number.
Indicate the nature of the illness in Section 12 and provide any relevant medical history as requested.
Sign and date the form at the bottom to authorize submission. Make sure to attach original itemized medical bills and a clear copy of your rental agreement before mailing it to HSR.

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Versions	Form popularity	Fillable & printable
2021	4.8 Satisfied (76 Votes)
2014	4 Satisfied (48 Votes)

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