NOTE: A Copy of the Estimate must be submitted together with this borderline form! RENAULT

Save-A-Car Request Form

Fields with * indicate mandatory information. Please complete All fields in order to submit.

Motor Body Repairer Information
MBR Name *
MBR Contact Person *
MBR E-Mail Address *
MBR Telephone No. *

Customer Information
Customer Name *
Contact E-mail *
Contact Number *

Vehicle Details
Vehicle Model *
Vehicle Reg. No. *
Vehicle VIN No. *
Vehicle Odometer Reading *
Vehicle Value *
Write-Off Threshold *
Estimate Vehicle Repair Total *
Date Parts Ordered Pick a date

Dealership Information
Dealership Province *
Renault Dealership *
Dealer Code
Dealer Parts Manager *
Manager E-Mail Address *
Dealer Contact Person (if different to above) *
Dealer E-Mail Address *
Dealer Contact Number *

Insurer Details
Insurance Claim Number *
Assessor's Name *
Assessor Contact Number *
Insurance E-Mail Address *

Additional Information

Please enter part numbers as entered on the Dealer invoice only

PART CODE* QUOTED PRICE* DEALER PRICE*