Repair Request Form

Repair Request Form

Please complete all fields based on the repair record and review the form carefully before submitting.
Vehicle and Customer Information
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Purchase Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Customer Name

First NameLast Name
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Current Mileage
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Vehicle Make/Model
VIN (last 4 numbers)
Driveable
Repair Status, Financials, and Insurance
Problem With Vehicle - Description

0/300
Key Policy Checklist
Once your form is received, a member of our service team will reach out to you to collect the repair fee of $200 and get your vehicle scheduled. All repairs take a minimum of 72 hours.
Completion and Signature
Customer's signature
Completion date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: