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MAKE A CLAIM

To better assist you in the claims process, please complete the following information:

Who is filing the claim:*
Dealer's Business Name:
Dealer Contact's First Name:*
Dealer Contact's Last Name:*
Dealer Phone Number:
Dealer Email Address:
Ultimar Warranty Number:*
Date of Ultimar Application:*
MM slash DD slash YYYY
Full Name on Warranty:*
Phone Number:*
Email Address:*
Street Address:*
Last 6 Digits of VIN:*
Ultimar Selling Dealer:*
Current Mileage:*
Select Type of Damage:*
RO Number:*
Estimate:*
Cause of Concern:
Images of the damage are required to validate your claim. Please attached 1-6 images. Each image file should not exceed 10MB of disk size.*
Drop files here or

Accepted file types: jpg, jpeg, gif, png, Max. file size: 10 MB, Max. files: 6.
Accepted file types: jpg, jpeg, gif, png.

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