P-507 Hired, Borrowed, or Leased Vehicle Information
Completed form and required documents will be submitted to info@gslpg.org or you may choose to submit by mail to: Lafayette Service Center 1720 Kaliste Saloom Rd. Suite C1 Lafayette, LA 70508
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Vehicle Information
Vehicle Engine/Serial #
*
Vehicle License Number
*
Vehicle Year
*
Vehicle Make & Model
*
Name of Rental Agency/Owner
*
Trip Information
Trip Destination
*
Departure Date
*
-
Month
-
Day
Year
Date
Return Date
*
-
Month
-
Day
Year
Date
Date of Vehicle Pickup
*
-
Month
-
Day
Year
Date
Date of Vehicle Return
*
-
Month
-
Day
Year
Date
Please attach Copy of Current Driver(s) Licenses for Each Driver
*
Browse Files
Cancel
of
Please attach Copy of Current Certificate of Insurance for Each Driver
*
Browse Files
This copy must show coverage amounts
Cancel
of
Please attach Copy of Signed Rental or Lease Agreement
*
Browse Files
Cancel
of
Please List all Drivers
*
First Name
Last Name
First Name
Last Name
First Name
Last Name
First Name
Last Name
Signature
Clear
Submit
Should be Empty: