Haywire Protection Claim Form

Name of RF (Repair Facility):

RF Address:

RF Phone Number:

Advisor/Service Writer Name:

Advisor Email:

Policy Holder Name:

Policy Number:

Last 6 of the VIN:

Vehicle Year/Make/Model:

Current Mileage:

Repair Order/Work Order Number:

Date Vehicle Arrived at RF:

Was the vehicle towed or driven in?

What are the customer's concerns?

If Advisor mentions check engine light, please have them give codes or include them on invoice they will fax or email in.

If customer mentions check engine light, how long has the light been on?

If customer mentions drivability issue (stalling out, won’t go over30 mph) or noise coming from the engine area/under the hood – let them know that they need to have the vehicle towed into the RF