File A ClaimEasy as filling out a form

STEP ONE - CONTACT INFORMATION

I AM THE *

Dealership Name

Service Advisor Full Name

Dealer Phone

Dealer Email *

Key Tag

RO Number

First Name *

Last Name *

Contact Phone *

Email *

Address

Apt, suite, etc.

Country

City

State

Zip code

STEP 2 - VEHICLE INFORMATION

Year *

Make *

Model *

Current Mileage on Vehicle *

VIN # *

Dealership *

Warranty Registration Number (optional)

When was vehicle purchased?

STEP 3 - CLAIM DESCRIPTION INFORMATION

Select Type of Damage *

Date Damage Noticed

Description of Damage

Damage Location

Cause of Damage

Size of Damage

Other

Methods to Remedy Damage?

Upload Image #1

Upload Image #2

Upload Image #3

STEP 4 - ACCEPTANCE AND SUBMISSION

IMPORTANT!

Please read the following statements carefully, as a claim will not be processed unless initials from the claimant / service advisor have been provided.

Please type your initials to indicate: I am aware that Eckbond Inc. relies on the information and statements above. I hereby certify that the above statements are complete and accurate to the best of my knowledge. I understand that any inaccurate information entered on this form could affect the outcome of the claim, including denial of claim.

Signature

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