Claim Form

All fields are * required.

Section 1: Contact information

Name: *


Current Address: *

City: *

State: *
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip Code: *

Phone: *

Email: *

Contact Preference:
Phone Email


Section 2: Vehicle information
VIN: *


Make: *


Model: *


Year: *


Xzilon^® warranty number:


Car Mileage *

Section 3: Claim description information

Section 4: Submission

IMPORTANT

Please read the following statements carefully. Claims will not be processed unless the full name of the claimant has been provided.

Please type your full name below to indicate:

I am aware that Xzilon^® relies on the information and statements above. I hereby certify that the above statements are complete and accurate to the best of my knowledge. I understand that any inaccurate information entered on this form could affect the outcome of the claim, including denial of claim.

Please note that it will take up to 24 hours to process an online claim.

Signature: *