File a Claim

TODAY'S DATE(Required)

BREAKDOWN/INCIDENT DATE(Required)

Company Name(Required)

Company Phone(Required)

Contact Name(Required)

Contact Phone(Required)

Contact Fax

Contact Email(Required)

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code Country

Dealership Name(Required)

Year(Required)

Please enter a number from 1980 to 2035.

Make(Required)

Model(Required)

VIN #(Required)

Brief description of breakdown/incident. Please include picture(s) of roadside service being provided or repair being performed.(Required)

ALL CLAIMS must be submitted within 30 days of the breakdown/incident.

File(s)(Required)

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 64 MB.

Phone

This field is for validation purposes and should be left unchanged.

To File a Claim In order to file a claim, you must do the following:

Complete the form above.
In the SUPPORTING DOCUMENTATION section at the bottom, include:
1. Invoice(s)/Repair Order for performed service(s) being submitted for reimbursement (with valid VIN # of covered unit).
2. Include pictures of the roadside service being provided or the repair being performed.
3. Proof of payment: credit card receipt or front and back copies of a check or cash receipt from service provider.