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PDR Service Contract Claim Form Claimant: Please fill out this claim form in its entirety and return it to Siskin Enterprises, Inc. at the address listed below. Your claim will not be initiated until this claim form is properly submitted. It is recommended that you keep a copy of the form for your records. INCOMPLETE CLAIM FORMS WILL BE RETURNED FOR COMPLETION CUSTOMER INFORMATION Name: _____________________________ Address: ____________________________ City: ______________________________ State: _________ Zip Code: ___________ Country: ___________________________ Primary Number:______________________ Secondary Number: ___________________ Fax: ______________________________ E-Mail: ______________________________ To expedite your claim please provide an email address SERVICE CONTRACT INFORMATION Service Contract Number: __________________________________ The contract Number is comprised of the alpha-numeric identifier located at the top right corner of your PermaPlate Service Contract Form. VEHICLE INFORMATION Make: ________________ Model: ________________ Year: ________________ Vehicle Identification Number: ______________________ Current Mileage: _____________ Date of Purchase: _____________ Purchasing Dealership Name: _____________________ CLAIM INFORMATION Specify the location of damage:_________________________________________________ Describe the approximate size of the damage: ____________________________________ Was the damage caused by hail? Yes / No / Unknown If the damage was caused by hail: • Has a claim been filed with your insurance carrier? Y / N • Does your comprehensive property damage insurance policy provide coverage for hail? Y / N If yes, please provide a copy of your in-force insurance card. *IN ORDER TO EXPEDITE YOUR CLAIM, PLEASE ATTACH A PHOTOCOPY OF BOTH SIDES OF YOUR SERVICE CONTRACT FORM AND/OR PICTURES OF THE DAMAGE* 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 may result in the denial of your claim and future related claims. Claimant Signature: ___________________________________ Date: SISKIN ENTERPRISES, INC. Manufacturer of PermaPlate Products Phone: (800) 453-8470 P.O. Box 58, Salt Lake City, Utah 84110 Fax: (801) 974-5559 E-mail: [email protected]