Product Details

Contact Name

Contact Email

Company Name

TGL Account Number

Part Number


Has item been fitted?

Customer Ref No

Vehicle Reg

Date Fitted

Date Removed

Mileage Covered

Fault Details

Reported Fault

If your fault is not listed, please describe

Additions to your Claim

Labour Claim

Hourly Rate


Time Taken (Hours)

Total Labour Cost

Ancillary Items

Quantity of additional parts claiming for

Part number or description

Total ancillary claim