Claims Submission Form

CONTRACT HOLDER INFORMATION
Customer First and Last Name*
EFG Contract Number
VEHICLE INFORMATION
Full Vehicle Identification Number (VIN)*
Vehicle Year, Make, and Model*
Current Odometer Reading*
REPAIR FACILITY INFORMATION
Repair Facility Name*
Repair Facility Phone Number*
Repair Facility Address, City, State, ZIP
Repair Facility Fax Number
Repair Cashier/Payment Email Address
Service Advisor Email Address*
VEHICLE REPAIR INFORMATION
Repair Order Date*

MM slash DD slash YYYY
Repair Order Number*
Customer Complaint*
Cause
Correction*
Labor Time Guide
Labor Hours Requested
Labor Rate
Sales Tax % (If Applicable)
UPLOAD REQUIRED DOCUMENTS

Please upload a copy of the estimate INCLUDING ALL PART NUMBERS REQUESTED by dragging the file below or by clicking “Select files” to browse and upload from your computer.

Please note: an incomplete estimate will result in a delay in claim approval.
Drop files here or

Max. file size: 700 MB.

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