C.I.S. Fast-Track Claim Form

730 Birginal Drive
Bensenville, Illinois 60106
Toll Free 888.345.2700
Fax 630.616.1705

> Fast-Track Claim Form

Please take a moment to fill out this form. A representative from C.I.S. will contact the insured. Fill out as much information as possible to help expedite the claim. If you have any questions, please include them in the bottom section of this form. Most Fast-Track claims are billed within three days.

Other services are available through our National Claim Form which include dash replacement, theft repair, odor removal, flood restoration, tire/wheel replacement, convertible top replacement, etc.

Wheel Claim Form

Insurance Company Information:

*Insurance Company:
*Claim Number:
*Adjusters Name/Team Number:
Adjusters E-Mail Address:
(Please include your E-Mail address for billing purposes and receipt of claim.)
*Phone Number: Ext. Number:
*Deductible: (If 0, please enter 0)
Remaining Deductible: (If applicable, please enter remaining amount due)
Additional Electronics Coverage: If Yes, How Much:
Betterment: If Yes, what %:

Insured's Information:

*Name:
Address:
City: State: Zip Code:
*Home Phone:
Work Phone:
Cell Phone / Pager Number:

Vehicle Information:

Make: Model:
Year: V.I.N. Number:
Vehicle Location:(if applicable)
Location's Number:(if applicable)

Theft or Damage Information

Equipment to be replaced:

Authorization to Proceed with Claim:

Please check the box below to authorize C.I.S. to proceed with your claim.

I hearby authorize C.I.S. to proceed with the submitted claim.

Questions or Comments:

Thank you for using C.I.S.'s Internet Claim Service!