Car Wash Damage Claim Form
This form must be completed within 72 hours of your incident.
You need to report damage to your vehicle with the site manager before you leave the car wash. Once you leave the facility we have no means of determining where your damage occurred. Leaving the facility without reporting the damage renders your claim invalid and your alleged damage/incident/accident will not be processed by our claims department. PLEASE NOTE: you must complete all fields and upload photos for your potential claim to be processed. Any missing information may delay processing.
Date of Incident
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Customer Information
Customer Name
First Name
Last Name
Contact Number
Please enter a valid phone number.
Email Address
example@example.com
Customer Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Car Wash Company
Superior Express Car Wash
Car Wash Address - Service Location
Street Number
Street Name
City
State / Province
Postal / Zip Code
Car Wash Service Received
Please Select
Basic Wash Express
Super Wash Express
Best Wash Express
Supreme Wash Express
Exterior Hand Wash
Full Service Hand Wash
Complete Exterior Hand Wash
The Works Hand Wash
Deluxe Hand Wash
FULL Exterior/Interior Detail
Exterior Detail Only
Interior Detail Only
Other Service(s)
Name of person you reported damage to at the car wash on day of incident:
Name
Title
Damage Details
After Car Wash
Description of the damage
Vehicle Information
Year
Color
Make and model
License Plate
Vehicle Identification Number (VIN)
Date
-
Month
-
Day
Year
Date
Please read and understand the following:
I state that my answers on this form are true and correct to the best of my knowledge. I certified that the timeframe of this claim is true to the best of my ability. I also understand that submitting this form does not indicate that Superior Express Car Wash has accepted responsibility for this matter and that responsibility will be determined after further investigation and analysis of the facts and circumstances relating to the incident. I further understand and agree that I am providing the requested information voluntarily in order to assist Superior Express Car Wash with investigating the incident, and that, by completing the claims form, I hereby grant my permission to Superior Express Car Wash to the information contained herein and that this form and any additional information may be sent to Superior Express Car Wash’s insurer or others involved in and investigating the incident.
Car Owner's Signature
Please verify that you are human
*
Submit
Submit
Should be Empty: