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?*

YesNo

Advisor Email*

example@example.com

Payment Email*

Preferred Payment Method

Credit Card AmexCheck

Labor Rate Per Hour*

Repair Shop Address*

Street Address

Street Address Line 2

CityState

Zip Code

Tax*

PartsLabor and Parts

Tax Rate %*

Customer Name*

First NameLast Name

Repair order number*

Vehicle Received Date*

Date

Mileage*

Towed in or Driven In*

TowedDriven

Date of Estimated Completion*

Date

VIN Number*

Contract Number if Known

Not required but helpful

ASE or Factory Certified Technicians*

YesNoNo customer is aware.

Warranty on parts and labor*

Warranty on Parts/Labor if other is selected

We require at least 12/12

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*

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. YOU CAN ALSO TEXT PHOTOS HERE 888-743-9890

Comments

Not required

If you encounter any difficulties while submitting this form, email claims@ascentadmin.com. Ensure that you include all the particulars outlined in the form at the time of your submission. It's important to note that this form is designated for repair facilities, and it is imperative that we receive all the requisite information to facilitate the processing of your claim. Omitting any information on this form will inevitably result in a delay in processing your claim.

We kindly request you to monitor the email address associated with your claim submission, as we will promptly respond once we have processed your claim. If any additional information is required, we will promptly inform you. You hereby affirm and warrant that all information provided in this document is true and correct to the best of your knowledge, belief, and understanding. Failure to submit accurate data may result in legal consequences, including but not limited to penalties, fines, or other legal actions.

Your cooperation is greatly appreciated. Thank you.

Submit your Claim

Contact Details

Job Description