Report a Claim – Preferred Repair Facility

Preferred Repair Facility Online Claim Form

Preferred Repair Facility Claim Form Instructions

Please complete all fields. Items marked with an asterisk (*) are required fields.

"*" indicates required fields

CUSTOMER INFORMATION

Customer Name*

First Last

Contract Number

Phone*

Vehicle Identification Number (VIN)*

Breakdown Date*

Breakdown Mileage*

PREFERRED REPAIR FACILITY INFORMATION

Preferred Repair Facility Name*

Preferred Repair Facility Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Fax

Hours of Operation*

Contact Person*

Contact Email*

Labor Rate*

Tax Rate on Parts*

Parts and Labor Warranty*

Tax Rate on Labor*

Customer Concern*

Do you need to submit documents for this claim? You may submit up to 6 documents below.

File

Drop files here or

Max. file size: 1 GB, Max. files: 6.

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