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
