Get Tx Hsr Payless Car Rental System Emergency Sickness Protection (esp) Claim Form 2021-2025

This guide provides step-by-step instructions on how to effectively complete the TX HSR Payless Car Rental System Emergency Sickness Protection (ESP) Claim Form online. By following these directions, you will streamline the claims process and ensure that your submission is accurate and complete.

Follow the steps to accurately complete your claim form.

1. Click ‘Get Form’ button to access the TX HSR Payless Car Rental System Emergency Sickness Protection Claim Form.
2. Begin by filling in the renter's name in the designated field. Ensure that the name is spelled correctly as it appears on your identification documents.
3. Provide the renter’s phone number, including the area code, to facilitate communication regarding the claim.
4. Enter the full address of the renter, ensuring to include street name, city, state, and zip code.
5. Fill in the name of the claimant, indicating last name, first name, and middle name as applicable.
6. Include the claimant’s daytime phone number, again with the area code, for any follow-up inquiries.
7. Input the claimant's address, ensuring to provide street name, city, state, and zip code.
8. List the social security number of the claimant to assist in verifying identity.
9. Record the birthday of the claimant in the specified format.
10. Specify the details of the accident, including the date and time when the incident occurred.
11. Provide information about the sex of the claimant, selecting either Male or Female.
12. Enter the email address of the claimant for electronic correspondence.
13. Indicate the place where the accident occurred. Be as specific as possible to avoid confusion.
14. Describe in detail how the accident occurred, providing all relevant information to support your claim.
15. Indicate whether you have received treatment for this injury prior to the insurance's effective date. If yes, provide names and addresses of treating physicians along with consultation dates.
16. Specify the name of the rental car company relevant to your claim.
17. Detail the address where the rental car was obtained, including street, city, state, and zip code.
18. Sign the form digitally to authenticate your claim. This signature will be regarded as a legal equivalent of a handwritten signature.
19. Date your signature to confirm when the form was signed.
20. After completing all required fields, review your entries for accuracy. Save any changes made to the form before finalizing.
21. Once verified, you can download, print, or share the completed form as necessary, adhering to the submission instructions regarding mailing or emailing to HSR.

Complete your TX HSR Payless Car Rental System Emergency Sickness Protection Claim Form online today to ensure timely processing.