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Please fill out the form below to submit a claim and if we can help you, we will contact you shortly.
Name (required)
Daytime Phone Number (required)
Email Address (required)
What state is the car registered in?
Please select State
Alabama
Alaska
Alberta
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
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Indiana
Iowa
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Louisiana
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Pennsylvania
Puerto Rico
Rhode Island
Saskatchewan
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Are you still under an original or extended manufacturers warranty?
Yes
No
Vehicle Year:
Vehicle Make:
Model of the vehicle
VIN
Date of Vehicle Purchase:
January
February
March
April
May
June
July
August
September
October
November
December
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
20
31
2019
2018
2017
2016
2015
2014
2013
2012
2011
Dealer from which the vehicle was purchased:
State Purchased:
Please select State
Alabama
Alaska
Alberta
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
Saskatchewan
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Has the airbag light come on without reason?
Yes
No
If yes, how many times?
Has the car been taken back to an authorized manufacturer dealership to address the problem?
Yes
No
If so, how many times?
Has your airbag unintentionally deployed?
Yes
No
Additional details:
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