Claim Submission Form
*Claim/PO #: Date: *Email:
Insurance Company: Insurance company contact name:
Customer's name: Dealership:
Contact name: Contact phone: Contact email:
_________________________________________________________________________________________
Car year: Car make: Car Model:
VIN #: OE part #:
General description of claim:
Type of damage: Bent (needs straightening) Cosmetic damage Both
Number of wheels to be repaired: 1 2 3 4 5
Does the damaged wheel hold air?: yes no
Location of damage: Driver front Passenger front Driver Rear Passenger rear Multiple Wheels
Explain any multiple wheel damage:
Type of wheel: OEM Aftermarket
Type of finish on the wheel: Polished Chrome Machined Painted
Additional notes/comments: _________________________________________________________________________________________
