Ethos Group Claims

Maintenance 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)

Choose Maintenance Items Below

Enter menu pricing (this is the total price you charge for the service). Maintenance plans have varied coverage and may not cover all items below.

Oil and Filter Change

Rotate Tires

Diesel Exhaust Fluid

Cabin Air Filter

Engine Air Filter

Differential Service

Brake Fluid Exchange

Coolant Exchange

Automatic Transmission Service

For all claims, the Completed Repair Order Signed by Contract Holder is required for payment.

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