File An Online Claim If you are human, leave this field blank.Repair facility detailsRepair facility name *Phone *Fax *Repair facility email *Repair Facility Address *State *Zip *Labor Time PER procedureLabor cost per hourPart PriceSales tax rateCustomer detailsContract numberCustomer first and last name *Customer phone *Email *Last 6 of VIN *Repair detailsRepair order *Current odometer reading *Loss date *Rental car issued *YesNoNumber of daysIs rental car through repair facility? *YesNoIf known, please provide rental agency detailsWas vehicle towed or driven in? *TowedDrivenIf known, please provide towing agency detailsIs this vehicle modified beyond manufacture specifications? *YesNoFor details:Is this vehicle used for business or commercial use of any sort? *YesNoFor details:Customer concernCauseMultiple concerns?YesNoCustomer concern 2Cause 2Customer concern 3Cause 3Customer concern 4Cause 4Customer concern 5Cause 5Customer concern 6Cause 6Recommended correctionsAdditional notes about repair detailsAttach repair order or estimateCaptcha *reCAPTCHA is required.Submit
