Step 1 of 4 25% Personal Contact InformationName* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code CountryUnited StatesCanadaPuerto RicoPhone*Fax NumberEmail By providing your email address, you agree to receive claim documents electronically. Vehicle InformationModel Year*Vehicle Make*Example: Mercedes, Porsche, Toyota, Chevrolet, Honda, etc.Vehicle Model*Example: Prius, C CLass, Accord, Impala, BoxsterVehicle Identification Number (VIN)*Current Odometer*Date Product Purchased Dealership Name* Claim Description InformationPlease specify the location of the damage*Please describe the approximate size of the damage*Was the damage caused by hail?*Select OneYesNoHas a claim been filed with your insurance carrier for hail damage?*Select OneYesNoDoes your comprehensive property damage insurance policy provide coverage for hail?*Select OneYesNoPlease provide a copy of your insurance card for hail coverage.4MB size limitSpecial handling instructions (i.e. vehicle is at dealership, located in gated community, etc.) Acceptance and SubmissionPlease read the following statements carefully, as a claim will not be processed unless initials from the claimant have been provided.Please type your initials to indicate: I am aware that Siskin Enterprises, Inc. relies on the information and statements above. I hereby certify that the above statements are complete and accurate to the best of my knowledge. Any fraudulent statements will result in invalidity of warranty. Initials of Acceptance*NameThis field is for validation purposes and should be left unchanged.