Policyholder - First Name: *    Last Name: *
Contract #: *    Last 6 of VIN: *    Current Miles: *
Who is submitting the claim?
, Contact Name:
Best Email: *    Best Phone: *
Brief Description of Problem: *
I acknowledge and understand that I am NOT authorized to move forward with repairs. This claim has NOT BEEN AUTHORIZED.
Please enter what you see:
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ASE PAIADA Better Business Bureau NIADA rider

4902 Carlisle Pike, PMB 229 • Mechanicsburg, PA 17050
Phone: 800-269-5544 • Fax: 717-691-8779