VIPLUXURYEXOTICCLAIMS

Title	VIP Team Intake Form
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Let us help you coordinate a seamless replacement experience.

Complete the form below and our Private Client Experience team will follow up with the agent/broker, adjuster, and policyholder to ensure all replacement needs and expectations are met.

Operating Hours:

Monday – Friday: 7:00 a.m. – 7:00 p.m. CT

Saturday: 8:00 a.m. – 5:00 p.m. CT

_{^{*This form is intended for Private Client claims only.}}

ERROR

Are you the policyholder, or are you submitting this as a referral?

Policyholder

Policyholder Information

Policyholder Name

Please enter Policy holder name

Policyholder Phone Number

Policy Holder Phone number

Policyholder Email Address

Policy Holder Email

Claim & Insurance Details

Insurance Carrier

This field is required

Do you plan on filing a claim? Yes or No

Claim Number (if Yes is selected above)

Renting Zip or Repair facility

Reservation Number (If already created)

Renting Zip or Repair facility

Referral

^{Agent/Broker Information}

Your name

This field is required

Agency/Brokerage

This field is required

Best Contact Number

This field is required

Email Address

This field is required

Body Shop Information

Body shop Name

This field is required

Phone Number

This field is required

Address and State

This field is required

Comments (Optional)

If a reservation has already been made, please include the reservation number to help us avoid duplication.

This field is required

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Let us help you coordinate a seamless replacement experience.

Reservations

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