Submit a Co-op Claim Using this Form
Customer Name
*
Republic Account Number
Dealer Level
CCE/Lib+/Select/Other
Credit Percentage
Ex.) Lib + / Select 50, CCE 60
Republic Branch
Manufacturer
Co-op Activity*
*
Billboard, Radio, TV, Digital, etv
Vendor (Who is billing you?)*
*
Claim Type
Ducted, Non Ducted, Other
Was this Claim Pre-Approved for Co-op
*
Yes
No
If pre-approved, please provide your co-op pre-approval #
Invoice Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Invoice Number*
*
Invoice Amount*
*
Taxes, shipping, and agency fees should be excluded
Enter Email*
*
Comfirm Email*
*
example@example.com
File Upload
Browse Files
Drag and drop files here
Choose a file
Submit your advertisement showing the artwork and how it was displayed, aninvoice from the vendor, and any notarizations required for aired media. Maxupload 20Mb. Up to 5 files may be attached.
Cancel
of
Additional File Upload
Browse Files
Drag and drop files here
Choose a file
Submit additional files here if needed.
Cancel
of
Additional Comments
Claim Number
Submit
Should be Empty: