Claims Form

Claims Form

To be filled out by the Dealership
1) Please select your MOC Representative from the dropdown list

2) Fill out the required fields

4) Use the upload button to submit a copy of the R.O.

NOTE: If you are filing a tire claim/roadside you should also use the upload button to upload a picture of the damage and a picture of the tread depth (with gauge included in the picture) You must also provide a clear picture of the tires D.O.T. number for approval. (will end in 4 numerical digits). Please submit the original photo files for review. (faxes/black & white scans of photos are not permitted)

5) Once you have completed the form and uploaded your images, click the SUBMIT button. You will receive an email confirmation once completed.

* You must provide the Claims Administrator with a statement of damages and repair cost with the following:
- Paperwork copy of the Invoiced Initial Repair Order showing the purchase/installation of MOC product
- Paperwork copy of the Estimated Repair Order (with parts/pricing)
- Paperwork copy of the invoiced/accounting Final Repair Order (with parts/pricing)
- Copy of Diagnostic of current concern (if applicable)
NOTE: if you are submitting a headlight claim, photos of the headlights prior to repair are required

NOTE: if you are submitting a quiet brake claim, photos of the brake pad life are required with measurements.

Ex: if rear 2 photos are required, if both front and rear 4 photos are required.

Claim reviews are processed Monday-Friday between 7:30 am est - 4:30 pm est. Atypical claims can take between 24-48 business hours. Please check your email to see if more information has been requested. (Example tire claim is typical. Transmission, engine, used car kit, are atypical)
1. Route Sales Representative*
Select one
2. Warranty Type*

3. Damaged Tire's D.O.T. Number*
Please include full D.O.T. code & photo with D.O.T. clearly visible **please do not include spaces**
4. Additional Information
5. Your Name*
6. Service Manager's Email*
example@example.com
7. Service Advisor's Email*
example@example.com
A) Alternate Email (secondary email)
example@example.com
8. Cashier's Email (for receiving digital payment)*
example@example.com
9. Current Repair Order Number (R.O.)*
10. Dealership's Name*
11. Dealership's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
12. Dealership's Phone Number*
13. Warranty Holder's Name*
First & Last name
14. Warranty Holder's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
15. Warranty Holder's Phone Number*
16. Vehicle Year*
16. Vehicle Make*
17. Vehicle Model*
18. Vehicle Mileage*
19. Vehicle's VIN*
20. Initial RO PDF/Scan (must show the purchase/installation of MOC product)*

Invoiced/accounting copy & or vehicle history list
Cancelof
21. Current RO PDF/Scan (invoiced/accounting copy showing breakdown of parts, labor, tax, & total)*

Invoiced/Accounting paperwork copy if repairs are complete; work order copy if repairs are pending approval
Cancelof
22. Photos of Damage*

Cancelof
23. Photos of D.O.T*

D.O.T. will end in 4 numerical digits which represent the week & year the tire was manufactured
Cancelof
24. Photos of Tread Depth with Depth Gauge*

Cancelof
25. Photos of Brake Pads*

Upload multiple images if needed
Cancelof
26. Photos of Headlights*

Upload multiple images if needed
Cancelof
Details
Optional - Please share some details with us to help us better understand

To Be Filled out By Service Personnel Only:
27. Service Manager Name*
28. Technician Name*
29. Service Advisor Name*
30. Parts Description
31. Parts Cost
32. Labor Cost
33. Total Cost of Estimate Repair
I have read the MOC Limited Warranty documents carefully and understand them completely. Any person who knowingly, and with intent to defraud, files a statement of claim containing any false or misleading information may be guilty of fraud, and may face criminal penalties in accordance with state law.

(Warranty document can be reviwed at https://mocmidatlantic.com/warranty/)
34. Service Advisor Signature*

Clear
35. Service Manager Signature*

Clear
Please verify that you are human*
Should be Empty:

Claims Form

To Be Filled out By Service Personnel Only: