Manual Claims Submission

RPS Claim Submission Form

"*" indicates required fields

Contact Name*

First Last

Phone*

Email*

Dealership Name*

Zip/Postal Code

Contract #

Customer name

First Last

VIN

Vehicle Odometer

Customer Complaint

Cause of Failure

Part Number & Prices

Requested Labor Hours for Repair

Labor Rate

Tax Rate

Labor Manual/Guide

Please also upload a copy of the contract and copy of the RO with this form

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 128 MB.