Email: Purchasing Dealership: Year: Make: Model: VIN: Current Mileage: Color: WARRANTY NUMBER: (please be sure to include the prefix in front of the numbers located on your warranty) TYPE OF CLAIM (check all that apply) Environmental Paint Corrosion Undercoating/Sound Shield Interior Stains Rips, Tears, Punctures & Burns Headlight Lens Black Molding & Trim Alloy Wheel IN ORDER TO EXPEDITE PROCESSING PLEASE INCLUDE THE FOLLOWING (only applying to claim type) Copy of your warrant.

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