Renewal Claims Form

Claims Form

To ensure expedient service, please be sure all information is complete and accurate. All pictures and requested material must be sent to Renewal within 30 days or the claim will be closed and a new claim will need to be filed. If you have any questions, you may call our toll-free claims hotline at 877-808-4649 and one of our knowledgeable claims representatives will be glad to assist you.

I am the:

Personal Information

Name

First Name

Last Name

Current Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Contact Phone

(###)

###

####

Contact Email

Contact Preference

Renewal Policy Number

Vehicle Information

VIN

Make

Model

Year

Current Mileage

Claim Description Information

Select Damage Type

select all that apply

Touch Screen Chip

Touch Screen Crack

Touch Screen Scratch

Select Damage Location

select all that apply

Navigation Screen

Other Touch Screen

Date of Damage

YYYY

Detailed Damage Description

Submission

IMPORTANT

Please read the following statements carefully. Claims will not be processed unless the full name of the claimant has been provided. Please type your full name below to indicate: I am aware that Renewal relies on the information and statements above. I hereby certify that the above statements are complete and accurate to the best of my knowledge. I understand that any inaccurate information entered on this form could affect the outcome of the claim, including denial of the claim.

Signature

REMITTANCE ADDRESS

4450 Weaver Pkwy ATTN Xzilon

Warrenville, IL 60555

QUICK LINKS

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