External Claim Form

Contract #

VIN

Model

Make

Year

Coverage Name

- Select -AFG EW&TAFG Smart 360Canadian Smart RiskChemical AppearanceDLP Windshield ProtectantDrive SmartDriver Protection PlusEtchExcess Wear And TearExotic Tire and WheelGAP CoverageIntellidrive VscIntellismart AutoIntellismart HomeInterior Extended CareInterior Extended CareInterior Extra CareKey CoverageLendor Total LossLuxury Gap UnlimitedMaintenance CoverageMonth To Month Service ContractMonth To Month Tire And WheelNew York GAP CoverageNitrogen Tire CoveragePaintless Dent/Ding CoveragePowersports VscQ-Shield ProtectionRoadside AssistanceService ContractSmart 360Smart AdvantageSmart Loan ProtectSmart Loan Protect 1000Smart Loan Protect 2500Smart Loan Protect 5000Smart Pack ComboSmart Risk AutoSmart Risk MarineSmart Risk Power SportsSmart Risk RVSmart TrackSuperior Smart ClubTire And WheelTotal Loss ProtectionUltimate Smart ClubUltimate Tire And WheelVehicle Service ContractsWindshield Coverage

Customer Name

Your Email For Confirmation

Customer Address

Customer Phone Number

Sold Date

Selling Dealership

Dealer Phone Number

Name of Repair Dealer

Service advisor

I don't know

What is your Service Associate’s name?

Service advisor phone number

Service advisor email

Date you experienced you loss or needed to file your claim

Has this issue occurred before

No

Yes

Was your vehicle towed to the service facility

No

Yes

Claim Description

Brief Description of what you are making claim for

Claim images

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