Claim Submission

Repair shop name*

Repair shop phone *

Service Advisor Name*

First NameLast Name

Advisor Direct Phone Number*

Is it ok to text you on this number regarding the claim? By checking yes, you agree to receive text messages from us. Message and data rates may apply. Message frequency varies. You will be able to Reply HELP for more information or STOP to opt out.*

YesNoOther

Are there any signs of Rideshare? Commercial use? Lift Kit or Modifications?*

Is there visible outside damage to the component in question?*

YesNoOther

Advisor Email*

example@example.com

Payment Email if different from advisor email

Labor Rate Per Hour*

Preferred Payment Method*

Credit Card AmexCheckOther

Repair Shop Address*

Street Address

Street Address Line 2

CityState

Zip Code

Within 50 miles of selling dealer?*

YesNoNot sureOther

Tax*

PartsLabor and PartsOther

Tax Rate %*

Customer Name*

First NameLast Name

Vehicle Year / Make / Model*

EX: 2017 Toyota Tacoma

Customer Phone Number*

Please enter a valid phone number.

Repair order number*

Vehicle Received Date*

Date

Mileage*

Towed in or Driven In*

TowedDrivenOther

Date of Estimated Completion*

Date

VIN Number*

Contract Number if Known

Not required but helpful

ASE or Factory Certified Technicians*

YesNoNo customer is aware.Other

Warranty on Parts and Labor*

Warranty on Parts/Labor if other is selected

We require at least 12/12. 6/6 Powersports.

Customer Complaint(s)*

Multiple complaints can be added here. Simply hit enter and label 1, 2, 3 etc.

Cause of Failure(s) (Please provide PPT and specific detail) We must know what was done to test this part for failure.*

Multiple complaints can be added here. Simply hit enter and label 1, 2, 3 etc.

Correction(s)*

Multiple complaints can be added here. Simply hit enter and label 1, 2, 3 etc.

Labor Times*

Parts*

You can email photos to adjusters@ascentadmin.com.

You can Text photos or videos to 833-574-0388.

Alternate link to upload large files and videos.

Photo Upload (Must have photos if the repairs failure can be seen) Upload photos of code pulls.

Parts estimate upload with part numbers, labor times, and description of repair. (Not required but helpful.)

Upload Relevant Files (if applicable) Photos must be emailed to claims@ascentadmin.com if you cannot upload here. A PHOTO MUST BE UPLOADED OR EMAILED FOR REPAIRS THAT CAN BE SEEN, OR THIS WILL HALT THE PROCESSING OF THE CLAIM. If there are codes we will also need photos of the codes.

Comments

Not required

Notice to Repair Facilities Regarding Claim Submission
If you experience any difficulties submitting the required form, please contact us at claimsteam@ascentadmin.com.
Business Hours Requirement
All submissions must be made during our normal business hours of 7:00 AM to 5:00 PM Arizona Time (AZ) M-F, 8:00 AM -2:00 PM Saturday. Submissions received outside of these hours will not be filed until the following business day..
Authorization Requirements

•Prior Authorization: No repairs may commence without explicit written authorization from us. Repairs performed without such authorization will not be compensated, and the policyholder will bear sole responsibility for any unauthorized work.
Submission and Follow-Up

•Email Monitoring: Please monitor the email address provided with your claim submission, as we will promptly communicate with you upon processing your claim. Should additional information be required, we will notify you accordingly.

•Affirmation of Accuracy: By submitting this form, you affirm and warrant that all information provided is true, accurate, and complete to the best of your knowledge and belief. Submission of false or misleading information may result in legal consequences, including but not limited to penalties, fines, or other legal actions.
We appreciate your cooperation and commitment to ensuring the accuracy and timeliness of your submission. Thank you for your attention to these matters.

Submit your Claim

Contact Details

Job Description