Basic Claim and Vehicle Data

Your First Name *

Your Last Name *

Your Company Name *

Street or PO Box *

City *

State *

Zip *

Your Telephone # *

Your Email *

Claim or File # *

Date of Loss *

Insured Name *

Claimant Name

Vehicle Year *

Vehicle Make *

Vehicle Model *

Current Mileage *

VIN *

Basic Claim Synopsis

In just a few sentences provide a synopsis of the claim. *

Questions For Vehicle Operator

What was the initial service request or complaint? (e.g.: Engine overheating, engine oil change, check engine light on, etc.) *

What was the initial service or repair performed? (e.g.: Repaired cooling system, basic oil change, repaired electrical system, etc.) *

Date of the service or repair? *

Mileage at the time of service or repair? *

What is the list of parts that were serviced or replaced? *

Approximately how far was the vehicle operated after the initial repair, service, or incident, in miles or time before a symptom was noticed? *

What were the first abnormal symptoms observed by the vehicle operator? (e.g.: Dash warning lights, abnormal engine sounds, lack of power, etc.) *

Questions for Repair Shop

What are the abnormal symptoms they have observed? (e.g.: Warning lights, abnormal engine noise, driveline vibration, etc.) *

What tests have they have performed? (e.g.: Cylinder compression test, manual oil pressure test, reviewed codes, etc…)

What Diagnostic Trouble "P" Codes have they obtained from the vehicle’s powertrain computer? (e.g.: P0521, P0130, P0195, etc., None or Unknown) *

What does the shop believe happened, which resulted in the powertrain damages? *

What parts if any have been removed or disassembled from the powertrain? *

What parts or assemblies do they believe are damaged?

Additional comments or information.

4 + 3 = ?Please prove that you are human by solving the equation *