EFFECTIVE 2/1/16

Fax Claim Authorization Request

Please prepare this Claim Authorization Request in conjunction with the Repair Order/Invoice and fax to 866-639-5583 to start a claim. For instruction or information call 855-807-2885 between the hours of 8:00 a.m. and 7:30 p.m. Eastern Standard Time Monday through Friday, 9:00a.m. and 12:00 p.m. on Saturday.

Complaint:

Cause:

Correction:

Part#: Desc.: Price: Qty: Labor Time:

Part#: Desc.: Price: Qty: Labor Time:

Part#: Desc.: Price: Qty: Labor Time:

Part#: Desc.: Price: Qty: Labor Time:

Part#: Desc.: Price: Qty: Labor Time:

Once your claim has been authorized and an Authorization Number has been provided, please attach this Claim Authorization Request to the completed Repair Order and any applicable items (sublet bills) and mail to:

ACA Claims P.O. Box 2085

Dublin, Ohio 43017 Or fax all items to 866-582-6040

ALL REPAIR ORDERS REQUIRE CUSTOMER SIGNATURE TO QUALIFY FOR REIMBURSEMENT

Customer Name: Date:

VIN/Contract #: RO#:

Mileage: Labor Rate: Tax Rate %:

Advisor: Phone #: Fax #: