TITANIUM CLAIM FORM

DISTRIBUTOR *

CUSTOMER

(Enter Vehicle Owners info Below)

First Name *

Last Name *

Street *

City *

State/Province *

ZIP/Postal Code *

Country *

Phone Number *

Email *

VEHICLE

(Enter Vehicle Info Below)

Year *

Make *

Model *

CLAIM

(Enter Your Claim Info Below)

Description of Claim Request *

Technician Diagnostic Report *

Drag & Drop Files, Choose Files to Upload

Please attach full statement of damage or diagnostic report for claim. (File Types Accepted: JPG, JPEG, PNG, PDF)

Supporting Documents *

Drag & Drop Files, Choose Files to Upload You can upload up to 5 files.

Please attach service history, estimates and all supporting documents related to this claim. (File Types Accepted: JPG, JPEG, PNG, PDF)

Acknowledgement *

Please confirm by checking the box

Following confirmation, the claim will be placed into our review queue. Please note that all claims are handled on a first come, first served basis.

When a Wynn’s Claims Team member begins reviewing your submission, To complete the claim all required documentation has been properly submitted and is in good order.

If additional information or missing documentation is identified during the review process, the Claims Team member will contact the submitting party to request the required items. At that time, the claim will be removed from active review and returned to the bottom of the review queue until the requested information is received and the claim returns to the top of the queue for review.

To help avoid delays in processing, it is imperative that all required paperwork and supporting documentation are submitted completely and accurately with the initial claim submission.

DEALER

(Enter Your Dealership Info Below)

Dealer Name *

Dealer Phone *

Dealer Email *

Dealer City *

Dealer State/Province *

Wynn's Distributor Contact Email *

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TITANIUM CLAIM FORM

CUSTOMER

VEHICLE

CLAIM

DEALER

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