Start a Claim

Step 1 of 3

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Resubmit Claim To Desk

File a Claim in 3 Simple Steps

Note to consumer: This form is intended to be filled out by your selected repair facility.

Acknowledgment*

By checking this box, the individual is made aware that by filing a claim, any parts supplied by the repair facility require a minimum of a 12-month warranty.

Acknowledgment*

By checking this box, the repair facility acknowledges that payment for an approved claim will not be issued until all repairs are completed, a signed final invoice has been submitted to Empire State Warranty, and a completed W-9 form has been received. The repair facility is responsible for providing a valid W-9 prior to payment processing

Is This a GAP Claim?

Gap claims are handled through our partner, Nation Safe Drivers. To file a gap claim, you can call the number listed on the contract and email gapclaims@nationsafedrivers.com.

Step 1: Basic Claim Information

First Claim?

Check here if this is your facility’s first time submitting a claim with Empire State Warranty

Service Center name*

Service Center Email*

Service Center Phone*

Advisor/Contact Name*

First Last

Labor Rate ($XXX/hr)*

VIN*

Year*

Vehicle Make*

Vehicle Model*

Current Mileage*

Please do not add any special characters

Repair Order Number*

Does this Vehicle Have Any Related Technical Service Bulletin(s)*

Brief Explanation (TSB)*

Routine claim (Tire rotation, brake pads, oil change)?*

Customers concern to start the claim?*

Has This Work Already Been Completed By Your Facility?*

Yes

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File a Claim in 3 Simple Steps

Step 1: Basic Claim Information

Step 2: Claim Details

Step 3: Estimate

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