Claim Form

		Contract Holder Information
			Name:
			
			Email:
			
		   	Phone:

Covered Vehicle Information

Make:

Model:

Year:

VIN #:

Repair Facility
			Describe failure & part(s) needed:
			
			Name of repair facility:
			
			Phone:
			
			Address:
			
			City:
			
State:
				ZIP:

Application/Contract Information

Contract no:

Delivery Information
			Contact name:
			
			Email:
			
		   	Deliver part(s) to:
		   	
		   	City:
		   	
State:
				ZIP:
				
			Attn:

Your claim will be processed in accordance with the terms of the warranty contract. We will email you our decision as soon as our claims department is done reviewing your claim. Thank you.

Insuring Technology One Light At A Time

Xenon warranties.com

Claim Form

Contract Holder Information

Covered Vehicle Information

Repair Facility

Application/Contract Information

Delivery Information

Insuring Technology One Light At A Time