CDW DECLINATION STATEMENT.

In (City)________________ , Date____________________ of 2016.

Mr (Mrs/Miss).., I.D or Passport Number .., Nationality
., for the present written Statement , accepts and hereby declares that in voluntary form
he/she declines CDW coverage (Collision Damage Waiver) that Europcar Tattersall ( Ca de Leasing
Tattersall S.A ) offered at the moment of rental. Plate number of the vehicle rented . according to
Rental Agreement # .. or any vehicle that is given in replacement related to the same Rental
Agreement. Therefore, any damage that this vehicle could have, including damages to third parties
involved in an accident, damages to the private or public property and theft will be charged to the
following credit card:

Credit Card Number:.

CREDIT CRAD BRAND:
Expiration Date:/.

If Europcar Tattersall, does not have immediate information of the total expenses of the vehicle due to a
mechanic inform needed or if the third party and/or public property damages could not be calculated
immediately, Europcar Chile will inform to the client , the complete detail (s) of the incurred expenses to
the following directions mentioned below.

Country:

City:

Adress:
Zip Code:

Phone:

E-mail:
Europcar Tattersall will be only responsible of giving to the client that was mentioned before, the complete
details of expenses will be charged to the mentioned credit card, not thus any management of
reimbursement that the Credit Card Bank of issue could provide to its client. Releasing Europcar Tattersall
of any responsibility derived from a no reimbursement of the responsible Bank.

Name:
ID. Or Passport:
________________________________
Signature

Headquarters : Amrico Vespucio 1373, Parque Industrial Enea, Pudahuel. Phone: 56-25983232
www.europcar.cl