Car Rental Insurance Claim Check List To facilitate prompt review of your claim, please complete the form

as indicated and provide the following documentation as it applies to your situation (please util ize the checklist to assist you in this effort): Complete enclosed claim form Submit a copy of rental car agreement Submit a copy of police report Submit a copy of the rental car company's accident report Submit a copy of the final bill from the auto body repair shop and/or rental car company Please Do Not Staple Documents Please return your claim forms to: Claims Department 300 Jericho Quadrangle P.O. Box 9022 Jericho, NY 11753 If you have any questions, please contact us at: 800-382-6841 or 516-741-5428 Our Customer Service Representatives look forward to assisting you

Frequently Asked Questions Q. How long does the claim process take once you receive my completed claim form ? A. On average, claim processing takes approximately 5 business days from our rev iew of all required documentation. Q. How do I submit my completed claim form? A. All completed claim forms, with all original supporting documentation, need t o be mailed to our office at the following address: BerkelyCare Claims Department 300 Jericho Quadrangle P.O. Box 9022 Jericho, NY 11753 You may also fax this information to 516-294-0268 or scan & email this informati on to myclaimform@berkely.com. When faxing or emailing your claim form, please ensure all pages of the claim form and supporting documentation are included in your submission. Please note - if you are faxing or emailing your claim information, please do no t also mail in hard copies. Q. How will I know if you've received my completed claim form? A. If you have provided us with an email address, you will receive notification via email of our receipt of your claim form. Otherwise, you will receive notification from our office via US Post al Service. Q. Is there a time limit on filing my claim? A. While there is no time limit on filing your claim or getting any documentatio n you may need to submit with the claim forms, we do encourage you to file your completed claim form as soon as po ssible to ensure all necessary documentation is available for review.

Car Rental Insurance Claim Form Part I - Name & Address Claimant(s): SEYMOUR WARDContact Name: Address: Claim Number: Phone: 3 BOB GRAY CIRCLE 757 232-3043 SEYMOUR WARD HAMPTON, VA 23666 11PLN17010 Part II - Claim Information Please provide the full details of the incident, including date, time, place and circumstances: Do you have any other insurance that has already provided coverage for this inci dent? If YES, please identify name, address and policy number of all other insurance i ncluding personal or commercial auto, travel club, credit card loss or collision damage waiver covera ge, etc.: What is the current status of that claim? eexccdw_cf *1682879*

Part III - Authorization I authorize any insurance company, any travel organization or agency, airline ca rrier, cruise line, tour operator, rental agency, hotel, motel or similar entity providing lodging on a rental/lease basis or any other person who may have knowledge regarding this claim to release any information requested regarding th is claim and the loss reported. understand this information will be used by UNITED STATES FIRE INSURANCE COMPANY , or its authorized representatives, for the purpose of evaluation and determining coverage for this claim. I know I have a right to receive a copy of this authorization upon request and agree that a photographic or facsimile copy of this authorization is as valid as the original. I agree that this authorization shall be valid for the duration of this claim. I understand that any person who knowingly and with intent to defraud or deceive any insurance company files a claim containing any materially false, incomplete or misleading information may be subject to prosecution for insurance fraud. Signed (Insured or authorized person) Part IV -We are Bound by Law to Advise You of the Following State Waivers Any person who knowingly presents a false or fraudulent claim for payment of a l oss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. This Insurance is underwritten by UNITED STATES FIRE INSURANCE COMPANY. All Statements Contained On This Form Are True & Complete To The Best Of My Know ledge Your Signature Date