Ethos Group
Claim Request Form
Fields marked '
*
' are required. Providing detailed claim information and uploading the Repair Order (RO) enables us to more efficiently review and process payment for this claim. We pay up to MSRP on part price and determine labor by referencing any national, publicized labor guide.
Customer Information
Customer's Full Name
*
VIN
*
Facility Information
Facility Name
*
Contact Name
*
Street Address
*
City
*
State
*
Select
Alabama
Alaska
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
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Postal Code
*
Email
*
Used for follow-up communication and to receive claim approvals
Phone Number
*
Labor Guide
Hourly Labor Rate
(if applicable)
Repair Information
RO Date
*
RO Number
Current Mileage
*
miles
Request Type
*
(select all that apply)
Maintenance
Paintless dent repair
Windshield repair/replacement
Stain Removal
Fabric Repair
Tire/wheel repair or replace
Paint repair
Vehicle Repair
Other
Concern 1
Customer Concern
*
Cause
*
Correction
*
Part #/Description
*
Part Price
*
Part Quantity
*
Add Part
Diagnosis Time
(if applicable)
Labor
(Hours or $ Amount)
*
Add Concern
Any additional parts, charges, or fees that are not accommodated by the form may be added to the comment section for consideration. For maintenance claims, please utilize menu pricing. A detailed breakdown of parts and labor is not required.
Additional Services
Towing Amount
(if applicable)
Covered up to $100
Rental Days
(if applicable)
days
Covered up to $35/day
Comments
File Upload
For all claims, the
Repair Order
is required for payment.
For non-mechanical repairs, documentation of
proof of damage
is required.
For towing and car rental services,
sublet form
is required.
If this claim has a concern with more than 6 parts, upload a photo of the part estimate
Drag and drop or
Browse
Only jpeg, png, and pdf formats
Up to 5 files at 4 MB per file
Submit Claim Request