Claim Form - Owner Essentials

Submit a Claim

*** Please note that ALL claims must have the following information, and our authorization, PRIOR to any repairs being made. Fields highlighted in red are required to Submit a Claim.

Customer Information
Customer Name*
Last 6 of VIN*
or Contract Number
Repair Facility Information
Name*
Contact Name*
Address*
Street Address Address Line 2 City State ZIP Code
Main Phone
Direct Phone
Payment Fax
Vehicle Information
VIN#
Year
Make
Model
Repair Information
Odometer Reading*
Reading Date
Date Format: MM slash DD slash YYYY
RO #*
Primary Concern*
Cause*
Correction
Part # & Description 1*
Part # & Description 2
Part # & Description 3
Part # & Description 4
Labor Operation & Time 1*
Labor Operation & Time 2
*** If there are additional concerns which need attention, please have part numbers and labor times available. A call back will be made to complete the claim process PRIOR to any repairs being made.

© 2019 Enterprise Financial Group, Inc. All Rights Reserved. Administered by Enterprise Financial Group, Inc. or one of its affiliated companies. Enterprise Financial Group of Florida, Inc. Florida License #60102

Submit a Claim

Customer Information

Repair Facility Information

Vehicle Information

Repair Information