Ethos Group Claims

Mechanical Repair 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. Filing this form does not imply that repairs are covered! Once the form is submitted we will review and respond back with either approval or request for additional information.

Customer's Full Name *

VIN *

Repair Facility Name *

Contact/Advisor Name *

Street Address *

City *

State *

Postal Code *

Contact/Advisor Email *

Used for follow-up communication and to receive claim approvals

Repair Facility Phone Number *

RO Date *

RO Number

Invoice or Work Order Number work as well

Current Mileage *

miles

Labor Guide

Hourly Labor Rate (if applicable)

Sales Tax Rate (if applicable)

Concern 1

Customer Concern *

Example: Vehicle has a coolant leak

Cause *

Example: Water pump failure

Correction *

For visible leaks or visible mechanical failures you can upload a picture to expedite processing. You can upload files at the bottom of the Claim Form.

Part Description*

Part Number*

Part Quantity *

Price Per Part*

You can upload a part list if you have more than 20 parts per concern! You can upload files at the bottom of the Claim Form.

Diagnosis Time (if applicable)

This value is the time to evaluate this concern. Additional concerns may be added

Labor (Hours or $ Amount) *

This value does not include diagnosis time.

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.

Towing Amount (if applicable)

Covered up to $100

Rental (if applicable)

days

Max rental benefit is 5 days at $35/day, based on labor required

For all claims, the Completed Repair Order Signed by Contract Holder is required for payment.
For non-mechanical repairs, documentation of proof of damage is required.
For towing and car rental services, Sublet Invoice/Receipt is required.
If this claim has a concern with more than 20 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