C.I.S. National Claim Form

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

> National 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. Depending on the claim, some information may not be necessary. If you have any questions, please include them in the bottom section of this form.

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

Electronics: Dash Damage:

Restoration Information:
Odor: Spills: Wheel/Tire:

Flood: Rodents/Bugs: Convertible Top:

Equipment to be replaced:

Services & Documentation

Questions or Comments:

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