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10543 S. Glenstone Pl. | Baton Rouge, LA 70810 | phone: 225.769.9923 | toll-free: 800.272.8000

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Mechanical Claim Form

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MECHANICAL CLAIM FORM
REPAIR FACILITY USE ONLY

Claim Information

Mileage *

R.O # *

R.O Date *

Customer/Facility Information

Customer Name *

Customer Phone

Policy #

Repair Facility *

Repair Phone *

Repair Fax

Email for Claim Reply *

VIN *

Year/Make/Model

Customer Complaint

Repairs Required

Parts

Qty. *

Part # *

Description *

Each *

USD

Part Total

$

Qty.

Part #

Description

Each

USD

Part Total

$

Qty.

Part #

Description

Each

USD

Part Total

$

Qty.

Part #

Description

Each

USD

Part Total

$

Qty.

Part #

Description

Each

USD

Part Total

$

Qty.

Part #

Description

Each

USD

Part Total

$

Qty.

Part #

Description

Each

USD

Part Total

$

Qty.

Part #

Description

Each

USD

Part Total

$

Qty.

Part #

Description

Each

USD

Part Total

$

Qty.

Part #

Description

Each

USD

Part Total

$

Qty.

Part #

Description

Each

USD

Part Total

$

Qty.

Part #

Description

Each

USD

Part Total

$

Parts Grand Total

$

Labor

Operation

Hours *

Rate *

USD

Labor Total

$

Operation

Hours

Rate

USD

Labor Total

$

Operation

Hours

Rate

USD

Labor Total

$

Operation

Hours

Rate

USD

Labor Total

$

Labor Grand Total

$

Sublets

Towing

USD

Vendor

Sublet Type

Sublet Amount

USD

Vendor

Sublet Type

Sublet Amount

USD

Vendor

Sublet Type

Sublet Amount

USD

Sublet Grand Total

$

Taxes

Tax Rate (percentage) *Ex: 9.45% = 9.45

Tax Rate (decimal)

Tax Parts?YesNo

Tax Labor?YesNo

Tax Sublets?YesNo

Parts Tax

$

Labor Tax

$

Sublet Tax

$

Tax Total

$

Totals

Parts Grand Total

$

Labor Grand Total

$

Sublet Grand Total

$

Tax Total

$

Policy Deductible

Rental Car?NoYes

Rental Car (# of days)

Daily Rental Amount

USD

Rental Total

$

Claim Total

$

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To provide the best experiences, we use technologies like cookies to store and/or access device information. Consenting to these technologies will allow us to process data such as browsing behavior or unique IDs on this site. Not consenting or withdrawing consent, may adversely affect certain features and functions.

Functional Functional Always active

The technical storage or access is strictly necessary for the legitimate purpose of enabling the use of a specific service explicitly requested by the subscriber or user, or for the sole purpose of carrying out the transmission of a communication over an electronic communications network.

Preferences Preferences

The technical storage or access is necessary for the legitimate purpose of storing preferences that are not requested by the subscriber or user.

Statistics Statistics

The technical storage or access that is used exclusively for statistical purposes. The technical storage or access that is used exclusively for anonymous statistical purposes. Without a subpoena, voluntary compliance on the part of your Internet Service Provider, or additional records from a third party, information stored or retrieved for this purpose alone cannot usually be used to identify you.

Marketing Marketing

The technical storage or access is required to create user profiles to send advertising, or to track the user on a website or across several websites for similar marketing purposes.

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