Customer Details

Name/Business Name






Registration Number




Delivery Date

Damage to vehicle/surface

Cause of damage

Is damage Interior or Exterior? (check one or both boxes)


Location of the vehicle at the time of damage (ie Garaged or on the street etc.)

Date the damage occurred

Time that the damage occurred

Date the damage was noticed

Time that the damage was noticed

Date that the contamination was cleaned or removed from surface

Time that the contamination was cleaned or removed from surface

Was the vehicle damaged or was there any unrepaired damage to the vehicle before the incident?
YesNo       If 'yes' please provide details:

Is the vehicle comprehensively insured?
YesNo       If 'yes' please provide details:

Please upload images of any damage (Max File Size 5MB)

Products Purchased

Paint Protection YesNo

Leather Protection YesNo

Vinyl Protection YesNo

Fabric & Carpet Protection YesNo

Window Tint YesNo

Electronic Protection YesNo

Perfexion Cosmetic RepairYesNo


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