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Please use this form to initate a new GAP claim
Contract Holder Information
First Name * Last Name *
Email Address *
Verify Email Address *
Address 1 *
Address 2 *
City *
Telephone Number *
State * Zip Code *
Preferred Contact Method *
Contract Number or Vehicle Identification Number *
Vehicle Year, Make, and Model (for verification) *
Loss Information
Date of Loss * Has your insurance company
deemed the vehicle a total loss? *
Type of Loss * Was a Police Report filed? *
  Please provide a brief statement describing the loss: *
Primary Insurance Information
Company Name *
Policy Number *
Claim Number *
Deductible *
Insurance Contact Name *
Contact Telephone Number *
Insurance Settlement
Amount *
Date Settled *
Lender Information
Company Name *
Address 1 *
Address 2 *
City *
State * Zip Code *
Primary Contact Name *
Contact Telephone Number *
Have you authorized your lender to speak to Protective regarding your loan? *
Required Documents
All of the documents named below are required to review your GAP claim.
You must attach at least one of the following documents to open your claim.
If you do not currently have all of your documents, you may submit additional documents at a later date.
The following document types can be uploaded: .JPG, .GIF, .PDF, .TIF. Maximum size for each file is 5MB.
New Car: MSRP (Manufacturer's Suggested Retail Price)/Factory Invoice
Insurance Valuation Report with Ending Mileage
Retail Installment Loan Contract
GAP Contract
Payoff as of Date of Loss Document
Payment History Document
Copy of Insurance Settlement Check
After Market Cancellable Contracts (i.e. Vehicle Service Contract, Theft Protection, LoJack, Etc, Credit Life, Disability, and Road Hazard)
Total Loss Settlement Breakdown
Police Report
Other, Additional Related Document (* *Not required* *)
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