NIU of Florida, Inc.
RV On Site Repair and Trip Interruption Reimbursement Claim Form

Member Information

Claim Number :

Today's Date :   mm/dd/yyyy
Date of Service :
mm/dd/yyyy
Contract #

Vehicle Owner:

Owner's Address

Owner's Home Phone : Alternate Phone:

Vehicle Year, Make, Model and Vin:

Location of Service (include street, city and state):

Reason for Service

Describe Parts Repaired:

Were repaired parts covered under RV Shield Service Agreement?: Authorization#:

Name of technician:
Phone number of technician:

Any person who knowingly, and with intent to defraud, files a statement of claim containing any false or misleading information may be guilty of fraud, and may face criminal penalties in accordance with state law.

I hereby swear and/or affirm that the information provided herein is true and correct.

______________________________

_____________________________

Signature of Contract Holder:

Date:

Please attach the following documents:

For On-Site Repair Reimbursement:

                        1. Original paid service provider receipt(s).

                       *Receipt must be itemized and include the repair facility address &

                        phone number, date of service, location of disablement where repairs

                        performed, and the cause of disablement.

For Trip Interruption:

1. Authorized repair order.

*Repair order must be itemized and include the repair facility address &

phone number, date repairs were initiated & completed.

                       2. Original paid receipts for meals, lodging, and alternate transportation.

Please be sure all information is correct before you continue.

*Member Information*
Claim Number :
Today's Date :	mm/dd/yyyy	Date of Service :		mm/dd/yyyy	Contract #
Vehicle Owner:
Owner's Address
Owner's Home Phone :				Alternate Phone:
Vehicle Year, Make, Model and Vin:
Location of Service (include street, city and state):
Reason for Service
Describe Parts Repaired:
Were repaired parts covered under RV Shield Service Agreement?:					Authorization#:
Name of technician:			Phone number of technician:
Any person who knowingly, and with intent to defraud, files a statement of claim containing any false or misleading information may be guilty of fraud, and may face criminal penalties in accordance with state law. I hereby swear and/or affirm that the information provided herein is true and correct.
______________________________				_____________________________
Signature of Contract Holder:				Date:

Please attach the following documents: For On-Site Repair Reimbursement: 1. Original paid service provider receipt(s). Receipt must be itemized and include the repair facility address & phone number, date of service, location of disablement where repairs performed, and the cause of disablement. For Trip Interruption: 1. Authorized repair order. Repair order must be itemized and include the repair facility address & phone number, date repairs were initiated & completed. 2. Original paid receipts for meals, lodging, and alternate transportation.
Please be sure all information is correct before you continue.