Product Details

Contact Name

Contact Email

Company Name

TGL Account Number

Customer Ref No

Part Number

Quantity

Has item been fitted?

Is the vehicle registered in the UK?

Vehicle Reg

Date Fitted

Date Removed

Mileage Covered

Make

Model

Engine

Year Manufactured

Fault Details

Reported Fault

If your fault is not listed, please describe

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Additions to your Claim

Labour Claim

Attach invoice

Attach Invoice

Hourly Rate

Currency

Time Taken (Hours)

Total Labour Cost

Ancillary Items

Quantity of additional parts claiming for

Part number or description

Total ancillary claim