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Home
Coverage
Coverage
Service
Vehicle Service Contracts
Claims
Claims
Claim Steps
Report a Claim
Document Upload
About Us
About Us
Careers
Contact Us
Request A Quote
(888)-503-0722
Menu
Home
Coverage
Coverage
Service
Vehicle Service Contracts
Claims
Claims
Claim Steps
Report a Claim
Document Upload
About Us
About Us
Careers
Contact Us
Request A Quote
(888)-503-0722
(888)-503-0722
Repair Facility 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
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