KrexInc.com

Road Hazard Reimbursement Form

INSTRUCTIONS:

You may also print this form or download & mail with copies of the repair orders to:

Krex, Inc.
Tire Program Reimbursement
450 Skokie Blvd, Bldg. 200
Northbrook, IL 60062

All fields are required.
DEALERSHIP INFO
Dealership Name :	*
Address :	*
Suite/Apt :
City :	*
State :	*
Zip Code :	*
Contact Phone :	*
E-mail :	*
VEHICLE INFO
Vehicle Owner's Name :	*
Make :	*
Model :	*
Year :	*
Last 8 digits of VIN :	*
Mileage :	*
SERVICE INFO
Tire Was :	*	Repaired Replaced
Date of Oil Change/Maintenance Service with Krex :	*
Repair Order Number :	*
Total Tire Repair or Replacement Charge :	*
I am submitting my reimbursement information as follows : (All files must be either jpg, tiff or pdf. Each file cannot be greater than 500 KB.)
Repair Order :	*
Tire Repair/ Replacement Order :	*