Report a Claim – Repair Facility

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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

Address

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

Contract Number*

Phone*

Vehicle Identification Number (VIN)*

Breakdown Date*

Breakdown Mileage

REPAIR FACILITY INFORMATION

Repair Facility Name*

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: 100 MB, Max. files: 6.

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