ECP CLAIM FORM
Toll Free: 800.323.3521
Toll Free Fax: 800.409.5195
Email: claims@ecpinc.net
PO Box 1098 Oak Brook, IL 60522
CUSTOMER INFORMATION
Name:
Date:
Address:
City:
State:
Zip:
Home Phone:
Cell Phone:
Email:
Purchasing Dealership
:
Year: Make: Model: VIN: Current Mileage: Color:
WARRANTY NUMBER:
(please be sure to include the prefix in front of the numbers located on your warranty)
TYPE OF CLAIM (check all that apply)
Environmental Paint Interior Stains Headlight Lens
Corrosion Rips, Tears, Punctures &
Burns
Black Molding & Trim
Undercoating/Sound Shield Alloy Wheel
IN ORDER TO EXPEDITE PROCESSING PLEASE INCLUDE THE FOLLOWING (only applying to claim type)
GENERAL CLAIM INFORMATION
Description, size & location of the damage:
Date the damage was initially identified:
INTERIOR EXPLANATION
(interior claims only – check all that apply)
Please check the material & the cause of the damage below. Please note below if there are multiple materials/causes.
Fabric Seats Vinyl/Leather Carpet Headliners & Floor Mats
Milk Rips & Tears General Dirt & Dust
Coffee/Tea Punctures
Bleach/Dye Burns
Ink Juice/Soda Type:
Crayon Grease Type:
Additional Comments:
ONCE ALL DOCUMENTATION IS RECEIVED, PLEASE ALLOW 3 BUSINESS DAYS FOR RESPONSE.
I certify that the above information is correct and accurate to the best of my knowledge.
Signature Date
IMPORTANT INFORMATION: Repairs should not be performed until written authorization has been received by
our Claims Department ANY UNAUTHORIZED REPAIRS WILL NOT BE REIMBURSED.
Copy of your warranty
Itemized estimate of repair
(Paint & Rust Only)
Color photos of the damage (Paint & Rust Only)
click to sign
signature
click to edit
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