Claim for Damage 2018-05-26T22:15:46+00:00

The following entry form is intended to assist in the proper review of a vehicle damage claim. The person completing this form is representing to be the owner of the vehicle and all responses are made according to the owner’s best knowledge. It is essential that the claimant give complete information in all entry fields.

Vehicle and Owner Information

First and Last Name (required)

Email (required)

Street Address

City

State

Zip Code

Phone

Vehicle or equipment type

Year

Make

Model

V.I.N.

Mileage

Engine size/type

Maintenance records kept, yes or no

Receipt of purchase, yes or no

Date Available for Inspection

Name of Sea Foam product

Please describe how the product was applied

Additional (if applicable)

Name of professional auto business

Business contact name

Street Address

City

State

Zip Code

Business Phone

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