File a Claim – Repair Facility

Repair Facility 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 (VIN) *

Breakdown Date *

Breakdown Mileage *

Repair Facility Information

Repair Facility Name *

Repair Facility Address *

Apt, suite, etc.

Country

City

State

Zip code

Phone *

Fax

Hours of Operation *

Contact Person *

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 Upload

File Upload

File Upload

File Upload

File Upload

File Upload