AUTO REPAIR FACILITY CLAIM FORM – MERIT

AUTO REPAIR FACILITY CLAIM FORM

First Name

Last Name

Policy Number

Customer Phone Number

Vehicle Identification Number (VIN)

Breakdown Date

Breakdown Mileage

Repair Facility Name

Street Address

City

State / Province / Region

Zip / Postal Code

Repair Facility Phone Number

Repair Facility Contact Person

Labor Rate

Tax Rate on Parts

Parts Warranty

Tax Rate on Labor

Customer Concern

Merit Administration | Wentzville, MO

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