Please note:  If you are dealership personnel filing a claim for a customer, please use the customers information to complete the form.

Step 1: Customer & Vehicle Information
First Name: Last Name:
Address: City:
State: Zip/Postal Code:
Home Phone: Work Phone:
Warranty Number: Vehicle Year:
Vehicle Make: Vehicle Model:
Vin #: Current Miles:
In your own words, describe your problem:
  Location of damage on the vehicle:
Description of the problem:
Date current damage was first Observed:
Material on which damage has occurred: (please check all that apply):
Explain Other:
Please check the box and explain the stain type, mark where indicated:
Explain Other:
Please mark the description for the damage on your vinyl or leather:
Explain Other:
PLEASE NOTE: If all required information is not submitted, it will delay the claims processing time.
 Please wait as your request is being processed