Customer Information:

Full Name *

Address Line 1 *

Address of Where Vehicle is Located

City *

State/Province *

Zip Code *

Phone Number *

Email *

Vehicle Information:

Year *

Make *

Model *

VIN *

Repair & Warranty Information:

Date of Original Repair *

Invoice Number: *

Description of Repair Performed *

Parts Replaced (if applicable)

Warranty Coverage Details (if known):

Issue Description:

Description of the Issue *

When did the issue first occur? *

Photos

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Has any other repair facility inspected or worked on the vehicle since our repair? *

If yes, provide details *

Customer Acknowledgment: I, the undersigned, hereby certify that the information provided above is accurate and complete. I understand that the repair shop will inspect the vehicle to determine warranty coverage, and any unauthorized repairs may void the warranty. I agree to allow the shop a reasonable amount of time to diagnose and address the issue. I acknowledge that I am responsible for any transportation fees associated with bringing the vehicle to and from the repair shop. I also acknowledge that any modifications to the vehicle, including hardware or software not equipped from the factory, will void any warranty coverage. Customer agrees to pay diagnostic fees in the event that the warranty claim is denied.

Signature *

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Date *

For Shop Use Only:

Date Received

Inspected By

Findings

Warranty Claim Status

Approved
Denied
Pending Further Inspection

Notes

Shop Representative Signature

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Date

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