File a Claim – Customer

Customer Claim Form

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

Customer Information

Customer Name *

Address *

Country

City

State

Zip code

Contract Number *

Email *

Phone *

Vehicle Identification Number *

Breakdown Date *

Breakdown Mileage

Repair Facility Information

Repair Facility Name *

Address

Apt, suite, etc.

Country

City

State

Zip code

Phone *

Fax

Hours of Operation

Contact Person

Contact Email

Customer Concern

Do you need to submit documents for this claim?

You may submit up to 6 documents below.

File Upload

File Upload

File Upload

File Upload

File Upload

File Upload

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