Blank Supplement Request Template - Quality auto body ...
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Supplement Request Form
**FOR SHOP USE ONLY**
Please complete ALL information on this form for all supplement requests.
E-mail completed form to R3ADSuppChi@ OR
Fax to 877-268-5058
***Please submit requests ONE claim at a time***
Please submit this form along with a list of supplemental damages.
No supplement will be honored unless authorized by GEICO.
Complete GEICO Claim Number: -
Example: XXXXXXXXXXXXXXXX-XX
Shop Email: @
Customer Name:
Vehicle Year: Make: Model:
Repair Facility Name: CDE Collision Damage Experts
Repair Facility Address: 2735 Bernice Road
Lansing, IL 60438
Repair Facility Contact:
Repair Facility Phone Number: 708-895-7999
Repair Facility Federal Tax ID#: 36-3312394
Is Vehicle at Repair Facility: Yes No
Additional Comments or Information:
................
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