Claims Submission Form

*** Please note that ALL claims must have the following information, and our authorization, PRIOR to any repairs being made.

Customer Information

Last 6 of VIN:*
or Contract #:
Customer Name:*

 

Repair Facility Information

Name:*
Contact Name:*
Address:*
City:*
State:*
Zip:*
Main Phone #:*
Direct Phone #:*
Payment Fax #:

 

Vehicle Information

VIN #:
Year:
Make:
Model:

 

Repair Information

Odometer Reading:*
Reading Date:
RO #:*
Primary Concern:*
Cause:*
Correction:*
Part # & Description 1:*
Part # & Description 2:
Part # & Description 3:
Part # & Description 4:
Labor Operation &
Time 1:*
Labor Operation &
Time 2:
   
  * Required Fields
   
  ** If there are additional concerns which need attention, please have part numbers and labor times available. A call back will be made to complete the claim process PRIOR to any repairs being made.