Servicer Request Form
Please provide all required fields
Vendor Account Manager:
*
Please Select
Amber Reed (Northern US)
Todd McCubbins (Southern US)
Maurice Griffin (National)
Associate Requesting Servicer:
*
Associate Email Address:
*
Date Requested:
*
-
Month
-
Day
Year
Date
Dealer Name:
*
Claim Reported Date:
*
-
Month
-
Day
Year
Date
Claim Number:
*
Customer's Name:
*
Customer's Phone:
*
Customer's Email:
example@example.com
Customer's City:
*
Customer's Zip:
*
Customer's State:
*
Please Select
AL
AK
AZ
AR
CA
CO
CT
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Vertical
*
Please Select
Technology
Furniture
Appliance
Fitness
Television
Other
Product Type:
*
Make:
*
Model:
*
Incident Description:
*
Has OEM Warranty been checked?
*
Please Select
Yes
No
Does it apply to any issue(s) reported?
Please Select
Yes
No
n/a
List servicer’s contacted and reason they cannot provide service:
*
Date Servicer Found & Associate Informed:
-
Month
-
Day
Year
Date
Service Request Submission:
Valid
Invalid
Service Not Located
Payment Method:
COD
Invoicing
Credit Card
Service Network Manager notes:
Submit
Should be Empty: