STEP ONE - CONTACT INFORMATION

STEP 2 - VEHICLE INFORMATION

STEP 3 - CLAIM DESCRIPTION INFORMATION

STEP 4 - ACCEPTANCE AND SUBMISSION

Please read the following statements carefully, as a claim will not be processed unless initials from the claimant / service advisor have been provided.

Please type your initials to indicate: I am aware that Eckbond Inc. relies on the information and statements above. I hereby certify that the above statements are complete and accurate to the best of my knowledge. I understand that any inaccurate information entered on this form could affect the outcome of the claim, including denial of claim.

CONTACT US

Phone number

+999 123 456 89

Email

hello@dream-theme.com

Address

121 Rock Sreet, 21 Avenue, New York,
NY 92103-9000

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