Get Tx Hsr Payless Car Rental System Emergency Sickness Protection (esp) Claim Form 2014-2025

This guide provides a detailed overview of the TX HSR Payless Car Rental System Emergency Sickness Protection (ESP) Claim Form and will walk you through the steps to complete it online. By following these instructions, you can ensure that your claim is filed correctly and without delays.

Follow the steps to successfully complete your claim form.

1. Click ‘Get Form’ button to retrieve the form and open it in the editing interface.
2. Enter the policy number as specified at the top of the form. This is crucial for identifying your claim.
3. Complete the renter’s report section by providing your name, phone number, and address. Make sure to include the area code for your phone number.
4. Fill in the name and address of the claimant, along with their daytime phone number, social security number, gender, and birth date.
5. Indicate the date and time when the illness first occurred, as well as the location where it took place.
6. In the section regarding sickness, describe the nature of the illness and any symptoms experienced.
7. If applicable, answer whether you had prior treatment for the illness. If 'yes,' provide the name and address of the treating physician and dates of consultation.
8. Provide details about the rental car company and the rental car address where the vehicle was obtained.
9. Sign and date the form as the renter, confirming the information provided.
10. Review all fields carefully to ensure that the form is complete. Attach original itemized medical bills and a clear copy of the rental agreement.
11. Mail the completed form and all attachments to the designated address: HSR Plaza, 4100 Medical Parkway, Carrollton, Texas 75007.

Complete your TX HSR Payless Car Rental System Emergency Sickness Protection (ESP) Claim Form online today to ensure prompt processing of your claim.