Claims Form

4. Additional Information
5. Your Name*
6. Service Manager's Email*
example@example.com
7. Service Advisor's Email*
example@example.com
8. Cashier's Email (for receiving digital payment)*
example@example.com
9. Current Repair Order Number (R.O.)*
10. Dealership's Name*
11. Dealership's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
12. Dealership's Phone Number*
13. Warranty Holder's Name*
14. Warranty Holder's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
15. Warranty Holder's Phone Number*
16. Vehicle Year*
16. Vehicle Make*
17. Vehicle Model*
18. Vehicle Mileage*
19. Vehicle's VIN*
20. Initial RO PDF/Scan*

Cancelof
21. Current RO PDF/Scan*

Cancelof
22. Photos/Scans of Damage*

Cancelof
Details
Optional - Please share some details with us to help us better understand

To Be Filled out By Service Personnel Only:
27. Service Manager Name*
28. Technician Name*
29. Service Advisor Name*
30. Parts Description
31. Parts Cost
32. Labor Cost
33. Total Cost of Estimate Repair
I have read the MOC Limited Warranty documents carefully and understand them completely. Any person who knowingly, and with intent to defraud, files a statement of claim containing any false or misleading information may be guilty of fraud, and may face criminal penalties in accordance with state law.
34. Service Advisor Signature*

Clear
35. Service Manager Signature*

Clear
Please verify that you are human*
Should be Empty:

To Be Filled out By Service Personnel Only: