WARRANTY CLAIM SUBMISSION FORM

Please fill in the following form to get your online claim submission started.

Vehicle Details

Registration Number:

Make / Model:

Current Mileage:

Customer Reported Fault

Customer’s Reported Symptom / Complaint:

Diagnosis

Initial Diagnosis:

Process of Diagnosis (steps/tests undertaken):

Final Diagnosis:

Repair & Cost Estimate

Parts Required:

Please give a detailed description and itemise a list with information on parts, their prices, and whether they include VAT (e.g. Alternator - £250+VAT)

Estimated Labour Hours:

Hourly Rate (£):

Total Labour Cost (£):

Supporting Evidence Uploads

Photos of fault/damaged component:

Diagnostic printouts:

Service history/maintenance record:

Invoice/estimate:

Other (please specify):

Repairer / Claim Submitter Contact Details

Business / Garage Name:

Contact Person:

Position/Role:

Phone:

Email:

Declaration

I confirm that the information provided is true and accurate to the best of my knowledge and that all supporting evidence has been submitted.

Signature:

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Date: