Maintenance Form

Submit your maintenance claim

Not for customer use. Repair facility only. Strictly for oil changes, tire rotations and other maintenance items. You must use the mechanical claims form for all mechanical repairs.
Contact Details
Repair shop name*
Repair shop phone *
Service Advisor Name*

First NameLast Name
Advisor Direct Phone Number*
Advisor Email*
example@example.com
Payment Email*
Preferred Payment Method*

Credit Card AmexCheckOther
Repair Shop Address*

Street Address

Street Address Line 2

CityState

Zip Code
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*

MonthDayYear
Date
Mileage*
Date of Estimated Completion*

MonthDayYear
Date
VIN Number*
Contract Number if Known
Not required but helpful
Services Performed*
Total for Service*
Upload the invoice*

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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.
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Submit your maintenance claim

Contact Details