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Please enter the required information before proceeding
{{ e.$name.replace('lastname','Last name').replace('firstname','First name').replace('phonenumber','Phone number').replace('emailaddress','Email address').replace('confirmEmail address','Confirm email address') }}
1. Customer Information
First Name
First name is required
Last Name
Last name is required
Phone Number
A valid 10-digit phone number is required
Alternative Phone Number
Preferred time for contact
Select one
Email address
A valid email address is required
Next
Please enter the required information before proceeding
{{ e.$name.replace('vin','Vin').replace('selectedVehicle make','Vehicle make').replace('SelectedModel','Vehicle model').replace('selectedYear','Vehicle year').replace('vehiclecontractnumber','Membership/Policy/Claim Number').replace('contractprovider','Contract provider').replace('mileage','Mileage') }}
2. Vehicle Information
Full Vehicle Identification Number(VIN)
This 17-digit number can be found on the windshield, the driver's doorjam or on your vehicle registration.
A valid 17-digit VIN is required
Vehicle Make
>
Select your vehicle make
Vehicle Make is required
Vehicle Model
Select your vehicle model
Vehicle Model is required
Vehicle Year
Select your vehicle year
Year is required
Mileage
Mileage is required
Membership/Policy/Claim Number
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Please enter the required information before proceeding
{{ e.$name.replace('ddlServiceReason','Problem with vehicle') .replace('ddldisablementLocationDetail','Disablement Location detail') .replace('ServiceType','Service Performed') .replace('ServiceDate','Date/Time of Service') .replace('ddlequipment','Type of equipment') .replace('spName','Service Provider Name (Damage)') .replace('vehicleDisablementLocation','Vehicle Disablement Location')}}
3. Service Performed
Service Performed
Select one
Service Performed is required
Date/Time of Service
Service Date is required
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Service Date is required
Problem with Vehicle
Select one
Problem with vehicle is required
Type of equipment
Select one
Equipment is required
Additional equipment used
Select one
Equipment is required
Service Provider Name (Damage)
Service Provider Name is required
Vehicle Disablement Location
Vehicle Disablement Location is required
Disablement Location detail
Select one
Disablement Location detail is required
Tow delivery location – Business name
Tow delivery location - Address
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4. Questionnaire
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{{qa.answer}}
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{{option.name}}
Please attach them to the documents section.
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Please enter the required information before proceeding
{{ e.$name.replace('damageLocation','Location of damage (on vehicle)') .replace('repairFacility','Repair Facility Name') .replace('repairFacilityPhonenumber','Repair Facility Phone Number') .replace('repairBreakdown','Total Cost of Damage') .replace('lossdesc','Description of Damage') .replace('ddlDamageType','Type of Damage') .replace('fileupld1','Supporting Photos/Videos are required') .replace('fileupld2','Repair estimate is required') .replace('fileupld3','Tow Slips/Damage Waiver is required')}}
5. Claim Information
Claim Details
Type of damage
Select one
Type of damage is required
Location of damage (on vehicle)
Location of damage is required
Repair Facility Name
Repair Facility Phone Number
Repair Facility Phone Number is required
Total Cost of Damage
Cost of Repair Breakdown is required
Description of Damage
Description of damage is required
{{1000 - CaseInfo.claimInfo.descriptionOfLoss.length}} characters remaining
Attach Supporting Photos/Videos
Attach clear and specific color photos of the area of alleged damage to your vehicle
Please make sure there is a date and time stamp (where available) on each of the photos taken
Pictures may be taken by you or your licensed repair facility of choice
The following photos are requested:
2-3 color photos of the overall damage to the vehicle
1 close up photo of the damage
2 pictures from 2-3 feet back
Color photos of the 4 points of the vehicle: Front, Rear, Left side, Right side.
Supported attachment format: JPG, JPEG, PNG, PDF, TIFF, GIF, AVI, MPG, MP4, WMV and 3GP
Attachment files should not exceed 12 MB size per attachment for photos and 30 MB size for videos
{{file}}
Add attachment
Supporting Photos/Videos are required
Attach Repair estimate
Attach a repair estimate from a licensed repair facility
The estimate for repairs has to be legible and on letterhead from the chosen licensed repair facility
The breakdown of repairs with their associated costs should also be included
The repairs specific to the damage should be clearly outlined in the repair estimate
Supported attachment format: JPG, JPEG, PNG, TIFF, GIF, PDF, TXT, DOC, DOCX, XLS, XLSX and RTF
Attachment files should not exceed 12 MB size per attachment
{{file}}
Add attachment
Repair estimate is required
Attach Tow Slips/Damage Waiver
Supported attachment format: JPG, JPEG, PNG, TIFF, GIF, PDF, TXT, DOC, DOCX, XLS, XLSX and RTF
Attachment files should not exceed 12 MB size per attachment
{{file}}
Add attachment
Tow Slips/Damage Waiver is required
{{ClaimInfo.IsValidFile}}
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6. Summary
1. Customer Information
Edit
First Name:
{{CaseInfo.customerInfo.firstName}}
Last Name:
{{CaseInfo.customerInfo.lastName}}
Email Address:
{{CaseInfo.customerInfo.emailAddress}}
Phone Number:
{{CaseInfo.customerInfo.phoneNumber}}
2. Vehicle Information
Edit
Full VIN:
{{CaseInfo.vehicleInfo.vin}}
Vehicle Make:
{{CaseInfo.vehicleInfo.make}}
Vehicle Model:
{{CaseInfo.vehicleInfo.model}}
Vehicle Year:
{{CaseInfo.vehicleInfo.year}}
Mileage:
{{CaseInfo.serviceInfo.mileage | number}}
Membership/Policy/Claim Number:
{{CaseInfo.vehicleInfo.policyNo}}
2. Service Performed
Edit
Service Performed:
{{CaseInfo.serviceInfo.servicePerformed}}
Date/Time of Service:
{{CaseInfo.serviceInfo.serviceDate | date:'MM/dd/yyyy'}}
Service Provider Name (Damage) :
{{CaseInfo.serviceInfo.serviceProviderName}}
Total Services Cost:
${{(CaseInfo.claimInfo.costOfRepairBreakdown) | number:2}}
Vehicle Disablement Location:
{{CaseInfo.serviceInfo.disablementAddress}}
Disablement Location detail :
{{CaseInfo.serviceInfo.disablementLocationDetail}}
4. Claim Information
Edit
Location of damage (on vehicle):
{{CaseInfo.claimInfo.locationOfDamage}}
Repair Facility Name:
{{CaseInfo.claimInfo.repairFacilityName}}
Repair Facility Phone Number:
{{CaseInfo.claimInfo.repairFacilityPhone}}
Total Cost of Damage:
${{CaseInfo.claimInfo.costOfRepairBreakdown | number:2}}
Description of the Damage and/or Loss:
{{CaseInfo.claimInfo.descriptionOfLoss}}
Supporting Documentation:
Supporting Photos/Videos:
{{file}}
Repair estimate:
{{file}}
Tow Slips/Damage Waiver:
{{file}}
By clicking on the above checkbox, I acknowledge that the information provided herein is true and accurate. I understand that withholding of information or giving false information may impact the resolution of my claim.
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