top of page
Hamburger Menu
Close
Home
Products
Our Team
Home
Products
Mechanical Breakdown
Credit Insurance
Pre-Paid Maintenance
GPS - Vehicle Locator
Ultimate Vehicle Protection
Vehicle Theft Protection
Safe-Shield Ceramic
Lease Wear & Tear
Guaranteed Asset Protection
Vehicle Service Contract
Precision Protect
Windshield Protection
Comprehensive protection products
sold exclusively through dealers.
Our Team
Contact
Login
Mechanical Claim Form
Repair Facility Use Only
Claim Submitted
Claim Information
Mileage
RO
RO Date
*
required
Customer/Facility
Customer Name
Customer Phone #
Policy #
Repair Facility
Repair Facility Phone #
Repair Facility Fax #
Email for Claim Reply
VIN
Year/Make/Model
Invalid Email
Customer Complaint
Repairs Required
Parts
Qty
Part #
Description
Each
Total
Qty
Part #
Description
Each
Total
Qty
Part #
Description
Each
Total
Qty
Part #
Description
Each
Total
Qty
Part #
Description
Each
Total
Qty
Part #
Description
Each
Total
Qty
Part #
Description
Each
Total
Qty
Part #
Description
Each
Total
Qty
Part #
Description
Each
Total
Qty
Part #
Description
Each
Total
Qty
Part #
Description
Each
Total
Qty
Part #
Description
Each
Total
Parts Toal
Labor
Operation
Hours
Rate
Total
Operation
Hours
Rate
Total
Operation
Hours
Rate
Total
Operation
Hours
Rate
Total
Labor Total
Sublets
Towing
Vendor
Vendor
Vendor
Sublet
Sublet
Sublet
Amount
Amount
Amount
Sublet Total
Taxes, Deductible, Rental
Tax Percentage
Tax Parts?
*
Yes
No
Tax Labor?
*
Yes
No
Tax Sublets?
*
Yes
No
Invalid Tax
Parts Tax
Labor Tax
Sublet Tax
Tax Total
Policy Deductible
# of Days for Rental Car
Daily Rental Amount
Rental Car?
*
Yes
No
Rental Total
Summary
Parts Total
Labor Total
Sublet Total
Tax Total
Deductible
Rental Total
Parts Total
Labor Total
Sublet Total
Claim Total
Tax Total
Rental Total
Deductible
Claim Total
Upload RO *Required
Max: 2 MB
Submit
* Required fields are blank
Home
Our Team
Contact
bottom of page
