File An Online Claim Online claim submissions are to be submitted by the licensed repair facility. Repair Facility DetailsRepair Facility Name(Required) PhoneService Writer's Name(Required) Repair Facility Email(Required) Repair Facility Address(Required) City(Required) State(Required) Zip(Required) Sales Tax Rate - Parts Sales Tax Rate - Labor Customer DetailsContract Number Customer First and Last Name(Required) Customer PhoneEmail Last 6 of VIN(Required) Repair DetailsRepair Order(Required) Current Odometer Reading(Required) Loss Date(Required) Part Price Labor Time PER Procedure Labor Cost Per Hour Rental Car issued(Required) Yes No Was vehicle towed or driven in?(Required) Towed Driven Is this vehicle modified beyond manufacture specifications?(Required) Yes No Is this vehicle used for business or commercial use of any sort?(Required) Yes No Cause(Required) Customer Concern(Required) Multiple Concerns? Yes No Customer Concern 2 Cause 2 Customer Concern 3 Cause 3 Customer Concern 4 Cause 4 Recommended Corrections(Required)Additional notes about repair detailsAttach repair order or estimateAccepted file types: jpg, png, pdf, , Max. file size: 15 MB.I'm humanNameThis field is for validation purposes and should be left unchanged.
