Online APPEARANCE PRODUCTS Claim Form
 Please Note: Fields marked with * are required fields.
Personal Contact Information
Name:*
Address:*
City:*
State:*
Zip Code:*
Phone:* (e.g. 000-000-0000)
Fax: (e.g. 000-000-0000)
Email Address:*

Vehicle Information
Model Year:* (e.g. 2007)
Vehicle Make:* (e.g. Ford)
Vehicle Model:* (e.g. Explorer)
VIN:*
Exterior Color:*
Interior Color:*
Current Odometer:*




Warranty Registration Information

The prefix letter(s) and number are located at the top right corner of your Customer Registration Form.
Prefix:* Number:*
Date Product Purchased:* Dealership Name:*



Please check all the areas that have been affected and the date(s) the damage was first noticed for each.
Please Note: Date(s) (MM/DD/YEAR) will be required in order to process claim.


 Paint Date Paint Damaged:     (IF Damaged, date required to process claim)
 Fabric Date Fabric Damaged:     (IF Damaged, date required to process claim)
 Leather/Vinyl Date Leather/Vinyl Damaged:     (IF Damaged, date required to process claim)
 Undercoat Date Undercoat Damaged:     (IF Damaged, date required to process claim)
 Rust Date Rust Damaged:     (IF Damaged, date required to process claim)




Describe, in detail, the cause and location on the vehicle, of each damage:*
(Please Note: This claim cannot be processed without a detailed explanation of exactly how and when the damage has occurred.)


Describe what attempts you have done to remedy the damage:


Describe any type of regular maintenance procedure used on your vehicle?


Initials of Acceptance
Please type your initialss to indicate: I am aware that PermaPlate Company LLC, 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 will result in invalidity of warranty.




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