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 - PartsSales Tax Rate - LaborCustomer DetailsContract NumberCustomer First and Last Name(Required)Customer PhoneEmail Last 6 of VIN(Required)Repair DetailsRepair Order(Required)Current Odometer Reading(Required)Loss Date(Required)Part PriceLabor Time PER ProcedureLabor Cost Per HourRental 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 2Cause 2Customer Concern 3Cause 3Customer Concern 4Cause 4Recommended Corrections(Required)Additional notes about repair detailsAttach repair order or estimateAccepted file types: jpg, png, pdf, , Max. file size: 15 MB.I'm humanCommentsThis field is for validation purposes and should be left unchanged.
