online claim form.
Please enter your details as they appear on your 'Fifth Dimension Registration Form'.
( Mandatory fields are marked with an asterix *)

Customer Details
Customer registration form No  
  Please attach your proof of purchase for a faster approval process.(Maximum File Size is 1MB)

Alternatively, please fax your proof of purchase through on 1800 629 462
Name *    
 
Address 
Suburb
State     PostCode   
Phone *
Email *
Certificate No
(if applicable)

Vehicle Details
Make *  
Model *
Rego # *
Vehicle Year
Chassis #
Application Date
Dealer *
Colour

Repairs
Please describe the repairs which you would like to claim (Bumper bar, Minor dent, Deep scratches, Stone chip, etc)
Product
Details

Other Comments
 
* I agree to the terms of the fifth dimension scratch n Dent safeguard warranty whereby the maximum claimable for an individual claim is $300 and as the owner, I am responsible for the first $30 of any individual claim.