Key Replacement Proof of Loss
CLAIM FORM

Member Information

Claim Number:

Full Name: Membership #:

Address: Apt #

City: State:       ZIP code:

Replacing Key Information

Date of Loss: mm/dd/yyyy Original Selling Dealership:

Cause of Loss

Description off facts and circumstances surrounding the loss/damage of the key(s):

Date Vehicle Purchased: mm/dd/yyyy Number of keys at time of purchase

Is key damage covered under your vehicle warranty?  Yes       No

Any person who knowingly, and with intent to defraud, files a statement of claim containing any false or misleading information may be guilty of fraud, and may face criminal penalties in accordance with state law.

Signature of Contract Holder: ___________________________________________________________ Date: _______________

Return all documentation to:
Claims Center
800 Yamato Road, Suite 100
Boca Raton, FL 33431
561-226-3600

Please be sure all information is correct before you continue.

*Member Information*
Claim Number:
Full Name:		Membership #:
Address:		Apt #
City:		State:	ZIP code:
*Replacing Key Information*
Date of Loss:	mm/dd/yyyy	Original Selling Dealership:
Cause of Loss
Description off facts and circumstances surrounding the loss/damage of the key(s):
Date Vehicle Purchased:	mm/dd/yyyy	Number of keys at time of purchase
Is key damage covered under your vehicle warranty? Yes No
Any person who knowingly, and with intent to defraud, files a statement of claim containing any false or misleading information may be guilty of fraud, and may face criminal penalties in accordance with state law. Signature of Contract Holder: ___________________________________________________________ Date: _______________
Return all documentation to: Claims Center 800 Yamato Road, Suite 100 Boca Raton, FL 33431 561-226-3600
Please be sure all information is correct before you continue.