Customer Name
Email Address
Phone number
Alternative phone number
Location of vehicle (city)
Vehicle Registration
Vehicle Make
Vehicle Model
When did you purchase your vehicle
  • - select year -
  • 2005
  • 2006
  • 2007
  • 2008
  • 2009
  • 2010
  • 2011
  • 2012
  • 2013
  • 2014
  • 2015
  • 2016
  • 2017
  • 2018
Month of purchase
  • - select month -
  • January
  • February
  • March
  • April
  • May
  • June
  • July
  • August
  • September
  • October
  • November
  • December
Please give as much information as you can about your issue
Where did you purchase it from
  • - select a option -
  • Franchised dealer
  • Independent garage
  • Private sale
  • Internet auction / EBay / Gumtree
  • Other
Name of Warranty Company
How did you pay for your vehicle?
  • - select a option -
  • All cash
  • All on debit card
  • All on credit card
  • Part cash part debit card
  • Part cash part credit card
  • Part debit card part credit card
  • Bank transfer
  • Purchased on finance (if Yes)
  • Name of finance company
Did you see the vehicle advertised for sale on a website before you purchased it?
Did you pay a deposit by debit card/credit card?
  • - select a option -
  • I paid a deposit by debit card
  • I paid a deposit by credit card
  • I paid a deposit by bank transfer
  • I paid a deposit by paypal
  • I paid a deposit by cheque
  • I did not pay a deposit
What month?
  • - select a option -
  • January
  • February
  • March
  • April
  • May
  • June
  • July
  • August
  • August
  • September
  • October
  • November
  • December
What year did you purchase your warranty?
  • - select a option -
  • 2010
  • 2011
  • 2012
  • 2013
  • 2014
  • 2015
  • 2016
  • 2017
  • 2018
Is your vehicle in a driveable condition?
What is the claim limit
  • - select a option -
  • £500 or less
  • £500 - £1000
  • £2000
  • £3000
  • £4000
  • £5000
  • £5000 - £10,000
  • Value of vehicle
How many years warranty
  • - select a option -
  • 3 months or less
  • 3-6 months
  • 6-12 months
  • 1 Year
  • 2 Year
  • 3 Year
  • 4 year
  • 5 year or more
My vehicle is currently located at
  • - select a option -
  • My home address
  • My local garage
  • With the vendor / vendors garage
  • repairing garage
  • Other – Please state

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