submit
claim

    Please enter the required information before proceeding
    • {{ e.$name.replace('vin','Vin').replace('selectedMake','Vehicle make').replace('SelectedModel','Vehicle model').replace('selectedYear','Vehicle year').replace('vehiclecontractnumber','Vehicle contract number').replace('ServiceDate','Service Date').replace('contractprovider','Contract provider') }}

1. Vehicle Information

Program Name
Client Name is required
Full Vehicle Identification Number(VIN)
This 17-digit number can be found on the windshield, the driver's doorjam or on your vehicle registration.
A valid 17-digit VIN is required
Vehicle Make
Vehicle Make is required
Vehicle Model
Vehicle Model is required
Vehicle Year
Year is required
Service Date
Service Date is required
Service Date is required
Service Contract or Membership Number
This is the unique number found in your contract.
A valid alphanumeric vehicle contract number is required
Where did you purchase the Service Contract or Coverage Protection Plan?
Service contract is required with the minimum of 3 characters
{{ClaimInfo.IsValidProfile}}
    Please enter the required information before proceeding
    • {{ e.$name.replace('mileage','Mileage').replace('tireRLrepaircost','Rear left repair cost').replace('tireRLlaborcost','Rear left labour cost').replace('tireRLtax','Rear left tax').replace('DamagedTireTreadDepthRLeft','Rear left damaged tire tread depth').replace('tireFLrepaircost','Front left repair cost').replace('tireFLlaborcost','Front left labour cost').replace('tireFLtax','Front left tax').replace('DamagedTireTreadDepthFLeft','Front left damaged tire tread depth').replace('tireRRrepaircost','Rear right repair cost').replace('tireRRlaborcost','Rear right labour cost').replace('tireRRtax','Rear right tax').replace('DamagedTireTreadDepthRRight','Rear right damaged tire tread depth').replace('tireFRrepaircost','Front right repair cost').replace('tireFRlaborcost','Front right labour cost').replace('tireFRtax','Front right tax').replace('DamagedTireTreadDepthFRight','Front right damaged tire tread depth').replace('keyrepaircost','Cost of service').replace('keyrepairlaborcost','Part & labour cost').replace('keyrepairtax','Tax') }}
    • Mileage

2. Service Performed

Service Performed
ServiceType is required
Mileage
Mileage is required
Inspection Required
Inspection Required is required
Include Broken Down Costs Where Applicable
If a specific value is not available, enter $0 in the respective field
Parts Cost Parts cost is required Invalid parts cost
Labor Cost Labor cost is required Invalid labor cost
Tax Tax is required Invalid tax
Total Cost: ${{ServicePerformedInfo.TotalCost=(ServicePerformedInfo.KeyRepairCost -- ServicePerformedInfo.KeyRepairLaborCost -- ServicePerformedInfo.KeyRepairTax) | number:2}}
Which Tires Were Serviced? Check All That Apply:
Please select any one of the checkbox
Provide the Cost Breakdown where applicable for each tire or wheel
It may be helpful for us if you provide the measurements of the wheels you are requesting repair/replacement for. Please provide this in the ‘Description of Loss’ section in the Claim Information screen
Damaged Tire Tread Depth Parts Cost Labor Cost Tax Total Anticipated Refund Amount
Front Left
Damaged Tire Tread Depth is required
Parts cost is required Invalid parts cost Labor cost is required Invalid labor cost Tax is required Invalid tax ${{ServicePerformedInfo.TireFLeftTotalCost=(ServicePerformedInfo.TireFLRepairCost -- ServicePerformedInfo.TireFLLaborCost -- ServicePerformedInfo.TireFLWheelWeightsCost -- ServicePerformedInfo.TireFLValveStemCost -- ServicePerformedInfo.TireFLTax) | number:2}} ${{ServicePerformedInfo.FLeftAnticipatedCost=(ServicePerformedInfo.TireFLeftTotalCost * ServicePerformedInfo.TreadDepthPercentageFLeft.percentage / 100.0) | number:2}} $0.00
Front Right
Damaged Tire Tread Depth is required
Parts cost is required Invalid parts cost Labor cost is required Invalid labor cost Tax is required Invalid tax ${{ServicePerformedInfo.TireFRightTotalCost=(ServicePerformedInfo.TireFRRepairCost -- ServicePerformedInfo.TireFRLaborCost -- ServicePerformedInfo.TireFRWheelWeightsCost -- ServicePerformedInfo.TireFRValveStemCost -- ServicePerformedInfo.TireFRTax) | number:2}} ${{ServicePerformedInfo.FRightAnticipatedCost=(ServicePerformedInfo.TireFRightTotalCost * ServicePerformedInfo.TreadDepthPercentageFRight.percentage / 100.0) | number:2}} $0.00
Rear Left
Damaged Tire Tread Depth is required
Parts cost is required Invalid parts cost Labor cost is required Invalid labor cost Tax is required Invalid tax ${{ServicePerformedInfo.TireRLeftTotalCost=(ServicePerformedInfo.TireRLRepairCost -- ServicePerformedInfo.TireRLLaborCost -- ServicePerformedInfo.TireRLWheelWeightsCost -- ServicePerformedInfo.TireRLValveStemCost -- ServicePerformedInfo.TireRLTax) | number:2}} ${{ServicePerformedInfo.RLeftAnticipatedCost=(ServicePerformedInfo.TireRLeftTotalCost * ServicePerformedInfo.TreadDepthPercentageRLeft.percentage / 100.0) | number:2}} $0.00
Rear Right
Damaged Tire Tread Depth is required
Parts cost is required Invalid parts cost Labor cost is required Invalid labor cost Tax is required Invalid tax ${{ServicePerformedInfo.TireRRightTotalCost=(ServicePerformedInfo.TireRRRepairCost -- ServicePerformedInfo.TireRRLaborCost -- ServicePerformedInfo.TireRRWheelWeightsCost -- ServicePerformedInfo.TireRRValveStemCost -- ServicePerformedInfo.TireRRTax) | number:2}} ${{ServicePerformedInfo.RRightAnticipatedCost=(ServicePerformedInfo.TireRRightTotalCost * ServicePerformedInfo.TreadDepthPercentageRRight.percentage / 100.0) | number:2}} $0.00
Total Cost: ${{ServicePerformedInfo.TotalCost = (ServicePerformedInfo.TireFLRepairCost -- ServicePerformedInfo.TireFLLaborCost -- ServicePerformedInfo.TireFLWheelWeightsCost -- ServicePerformedInfo.TireFLValveStemCost -- ServicePerformedInfo.TireFLTax -- ServicePerformedInfo.TireFRRepairCost -- ServicePerformedInfo.TireFRLaborCost -- ServicePerformedInfo.TireFRWheelWeightsCost -- ServicePerformedInfo.TireFRValveStemCost -- ServicePerformedInfo.TireFRTax -- ServicePerformedInfo.TireRLRepairCost -- ServicePerformedInfo.TireRLLaborCost -- ServicePerformedInfo.TireRLWheelWeightsCost -- ServicePerformedInfo.TireRLValveStemCost -- ServicePerformedInfo.TireRLTax -- ServicePerformedInfo.TireRRRepairCost -- ServicePerformedInfo.TireRRLaborCost -- ServicePerformedInfo.TireRRWheelWeightsCost -- ServicePerformedInfo.TireRRValveStemCost -- ServicePerformedInfo.TireRRTax) | number:2}}
Total Anticipated Reimbursement Value : ${{ServicePerformedInfo.TotalAnticipatedCost = (ServicePerformedInfo.RRightAnticipatedCost -- ServicePerformedInfo.RLeftAnticipatedCost -- ServicePerformedInfo.FLeftAnticipatedCost -- ServicePerformedInfo.FRightAnticipatedCost) | number:2}}
Please note that the above anticipated refund value is an estimate provided to you for your convenience. The actual amount you will be reimbursed for is based on the specific details of your service contract/coverage protection plan, and our claims team’s subsequent review of your submitted claim
{{ClaimInfo.IsValidCoverage}}
    Please enter the required information before proceeding
    • {{ e.$name.replace('lastname','Last name').replace('firstname','First name').replace('phonenumber','Phone number') }}

3. Customer Information

First Name
First name is required
Last Name
Last name is required
Phone Number
A valid 10-digit phone number is required
    Please enter the required information before proceeding
    • {{ e.$name.replace('repairordernumber','Repair order number').replace('LossDate','Date of loss').replace('ServiceDate','Service date').replace('lossdesc','Description of loss').replace('usertype','User type').replace('BestTime','Best time to contact').replace('dealerphonenumber','Dealer phone number').replace('dealername','Dealer name').replace('dealercontactname','Dealer contact name').replace('dealeremailaddress','Dealer email address').replace('dealerzip','Dealer ZIP').replace('PaymentTo','Payment to').replace('PreferredPayment','Payment method').replace('notificationemail','Notification email').replace('notificationconfirmemail','Notification confirm email').replace('payeecity','Payee city').replace('payeezip', 'Payee ZIP').replace('payeestreet','Payee street').replace('customeremailaddress','Customer email address')}}
    • User type
    • Notification confirm email

4. Claim Information

Claim Details

Repair Order Number
Document which usually contains the charges, labor and other costs
A valid alpha numeric repair order number is required
Date of Loss
Loss Date is required
Loss Date is required Loss date must be lower than Service date
Description of the Loss
Description of loss is required {{1000 - ClaimInfo.LossDescription.length}} characters remaining
Attach Supporting Documentation (Final Repair Order)
  • Claims will not be processed until a copy of the repair order is received
  • Attach now or provide later by responding to the claim confirmation email
  • Supported attachment format: TIFF, PDF, JPEG, BMP, PNG and GIF
  • Attachment files should not exceed 12 MB size per attachment
{{ClaimInfo.IsValidFile}}
I am a...
Please select the user type
This is the Best Time to Contact Me

Dealership Information

Dealership Phone Number
  • Tip - Enter the dealership's main phone number to pre-populate dealer information
A valid 10-digit phone number is required
Dealership Name
Dealership name is required
Dealership Contact Name
Dealership contact name is required
Dealership Email Address
A valid email address is required
Dealership Country
Country is required
Dealership ZIP Code
A valid zip is required

Payment Information

Payment To
Payment to is required
Preferred Payment Method
Preferred Payment mode is required
Which Email Address Do You Want To Be Notified of Your Payment?
A valid email address is required A valid email address is required Maximum 36 Characters Allowed

Customer Mailing Address:

Payee Mailing Address:

Email Address
A valid email address is required
Country
Country is required
Search for an Address
Street Address
Street is required
Apt/Suite/Floor(optional)
City
City is required
State
State is required
ZIP Code
A valid zip is required

5. Summary

1. Vehicle Information Edit

Full VIN: {{VehicleInfo.VIN}}
Vehicle Make: {{VehicleInfo.Make}}
Vehicle Model: {{VehicleInfo.SelectedModel}}
Vehicle Year: {{VehicleInfo.SelectedYear}}
Membership Number: {{VehicleInfo.ContractNumber}}
Service Contract Provider: {{VehicleInfo.ContractProvider}}
Service Date: {{VehicleInfo.ServiceDate | date:'MM/dd/yyyy'}}

2. Service Performed Edit

Service Performed: {{ServicePerformedInfo.Service}}
Mileage: {{ServicePerformedInfo.Mileage | number}}
Inspection Required: {{ServicePerformedInfo.InspectionRequired}}
Serviced Tires: {{ServicePerformedInfo.SelectedWheels.join(", ")}}
Damage Tire Tread Depth: {{ServicePerformedInfo.DamageTreadDepthCollection}}
Total Services Cost: ${{(ServicePerformedInfo.TotalCost) | number:2}}
Total Anticipated Reimbursement Value: ${{(ServicePerformedInfo.TotalAnticipatedCost) | number:2}}

3. Customer Information Edit

First Name: {{CustomerInfo.FirstName}}
Last Name: {{CustomerInfo.LastName}}
Phone Number: {{CustomerInfo.PhoneNumber}}

4. Claim Information Edit

Repair Order Number: {{ClaimInfo.RepairOrderNumber}}
Date of Loss: {{ClaimInfo.LossDate | date:'MM/dd/yyyy'}}
Description of the Damage and/or Loss:

{{ClaimInfo.LossDescription}}

Supporting Documentation:

{{ClaimInfo.File1Upload}}

{{ClaimInfo.File2Upload}}

{{ClaimInfo.File3Upload}}

I am a: {{'Customer' == ClaimInfo.UserType ? 'Customer' : 'Dealer' }}
Best Time to Contact Me: {{ClaimInfo.BestTimeToCall}}
Dealership Phone Number: {{ClaimInfo.DealerPhoneNumber}}
Dealership Name: {{ClaimInfo.DealerName}}
Dealership Contact Name: {{ClaimInfo.DealerContactName}}
Dealership Email Address: {{ClaimInfo.DealerEmail}}
Dealership ZIP Code: {{ClaimInfo.DealerZIP}}
Dealership Country: {{ClaimInfo.DealerCountry}}
Payment To: {{ClaimInfo.PaymentTo}}
Preferred Payment Method: Check
Preferred Payment Method: {{ClaimInfo.PreferredPayment}}
Notification Email Address: {{ClaimInfo.EmailAddress}}
Payee Mailing Address:
Customer Mailing Address:

{{ClaimInfo.PayeeStreet}}
{{ClaimInfo.PayeeCity}}, {{ClaimInfo.State}} {{ClaimInfo.PayeeZIP}} {{ClaimInfo.Country}}

Payee Mailing Address:
Customer Mailing Address:

{{ClaimInfo.PayeeStreetNo}}
{{ClaimInfo.PayeeCity}}, {{ClaimInfo.State}} {{ClaimInfo.PayeeZIP}} {{ClaimInfo.Country}}

Payee Mailing Address:
Customer Mailing Address:

{{ClaimInfo.PayeeStreetNo}}, {{ClaimInfo.PayeeStreet}}
{{ClaimInfo.PayeeCity}}, {{ClaimInfo.State}} {{ClaimInfo.PayeeZIP}} {{ClaimInfo.Country}}

Payee Mailing Address:
Customer Mailing Address:

{{ClaimInfo.PayeeCity}}, {{ClaimInfo.State}} {{ClaimInfo.PayeeZIP}} {{ClaimInfo.Country}}

Email Address: {{ClaimInfo.CustomerEmailAddress}}
Customer Mailing Address:

{{ClaimInfo.PayeeStreet}}
{{ClaimInfo.PayeeCity}}, {{ClaimInfo.State}} {{ClaimInfo.PayeeZIP}} {{ClaimInfo.Country}}

Customer Mailing Address:

{{ClaimInfo.PayeeStreetNo}}
{{ClaimInfo.PayeeCity}}, {{ClaimInfo.State}} {{ClaimInfo.PayeeZIP}} {{ClaimInfo.Country}}

Customer Mailing Address:

{{ClaimInfo.PayeeStreetNo}}, {{ClaimInfo.PayeeStreet}}
{{ClaimInfo.PayeeCity}}, {{ClaimInfo.State}} {{ClaimInfo.PayeeZIP}} {{ClaimInfo.Country}}

Customer Mailing Address:

{{ClaimInfo.PayeeCity}}, {{ClaimInfo.State}} {{ClaimInfo.PayeeZIP}} {{ClaimInfo.Country}}

Email Address: {{ClaimInfo.CustomerEmailAddress}}
Services are provoide by and/or through Cross Country Motor Club, Inc., Medford, MA 02155, except in Alaska, California, Hawaii, Oregon, Wisconsin,
and Wyoming where services are provoided by and/or through Cross Country Motor Club of California, Inc., Thousand Oaks, CA 91360.
Cross Country Motor Club, Inc. © Copyright 2019