Application for Certification Form
Consumer Complaint Form
Consumer Complaint Form
Consumer
Date:
Complainants Name, Mr. Mrs. Ms.
Address: Street City State
Phone:
Home
Work
Cell
Email:
Best way to contact:
Repair
Reason for Initial Repair. (Crash-Maintenance):
Reason for Complaint :
Repair Failure:
Warranty Breach:
Advertising:
Administrative:
Safety Issue:
Other:
Vehicle
Year:
Make:
Model:
Date of Repair:
Attempts to Resolve or Correct
Date/Reason Return Visit 1:
Date/Return Return Visit 2:
Additional Visits:
Insurance
Date of loss:
Name of Company if Applicable:
First Party Claim(your ins co.):
Third Party Claim
(someone else’s ins co.):
Name of Appraiser:
Name of Adjuster:
Insurance Referral Shop:
Consumer Selected Shop:
Amount
Total cost of repair invoice:
Estimated cost of re-repair if known/applicable:
Who inspected vehicle for re-repair:
Desired remedy:
Has another shop inspected the car?
Name of inspection shop and contact person:
Settlement amount desired:
When is vehicle available for inspection?
Would you be available to testify?
Other Contact:
(Spouse/Parent/Lawyer):
Phone:
