MBG Claim Form

PARTNER ACCOUNT NUMBER: *

PARTNER NAME *

PARTNER CITY: *

PARTNER ST/PROV: *

PHONE: *

PARTNER EMAIL: *

Confirm Email

CERTIFICATE NUMBER: *

VEHICLE OWNER *

First

Last

VIN#: *

CURRENT MILEAGE: *

DATE OF REFUND TO CLIENT: *

HOW REFUNDED: *

UPLOAD PHOTO (max size - 2 MB): *

Click or drag a file to this area to upload.

TERMS: *

By checking this box, I agree I have verified the damage to the vehicle and refunded my client for the full value of their original purchase price. No extraordinary circumstances or misuse has been detected. The windsield was damaged beyond repair. I agree that all terms and conditions of the partner agreement were followed. Re-coating, free items or trades given in lieu of monetary refund do not qualify for a guarantee. I understand that Sharpline Converting Inc. must verify the claim for accuracy and approval before a refund can be given.

PARTNER NAME OF PERSON COMPLETING FORM: *

First

Last

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