MAKE A CLAIM To better assist you in the claims process, please complete the following information: Who is filing the claim:*Please SelectContract HolderDealerDealer's Full Name:Dealer Phone Number:Dealer Email Address: Ultimar Warranty Number:*Date of Ultimar Application:* Date Format: 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:*Please SelectPaintDentAlloy wheelHeadlightCarpetUpholsteryRO 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. Accepted file types: jpg, jpeg, gif, png. This iframe contains the logic required to handle Ajax powered Gravity Forms.