Direct Bill to Insurance Application

GTA Accessible Transportation Inc

Direct Billing Insurance Account Application

Today's Date *

Name of the person setting up this account *

Phone Number of a Person's setting up this account *

Extension

Email Address of a Person setting up this account *

BILL TO (Insurance Company): *

Billing Address *

Apt, suite, etc.

Country

City

State

Zip code

Billing Fax Number

Billing Email

Adjuster's Full Name *

Adjuster's Phone Number *

Extension

Adjuster's Email Address

Select Invoice Option *

How do Like to receive Your Invoice

Claim Number *

Does Client Requires Wheelchair Accessible Vehicle

YES

Passenger"s Full Name

Passenger's Home Phone

Passenger's Mobile Phone

Passenger's Email

Passenger's Address *

Country

City

Restrictions

Please let us know if there are any restrictions on travelling locations

Frequent Travelling Addresses

Special Instructions

Signature *

Signature is required.