Claimant Verification Information Clause Samples

Claimant Verification Information. Yes No 1. Did you purchase or lease a 2013-2016 Nissan Altima vehicle? If so, please provide the following information: Model Year Model Vehicle Identification Number (If you received a postcard notice, your VIN is Identified on the notice) 2. Did you pay out of your own pocket – in whole or in part – for replacement of or repair to the transmission assembly (including torque converter and/or valve body) or Automatic Transmission Control Unit (ATCU) in your vehicle? If you paid to have the transmission assembly repaired more than once, you should include all payments you made for all repairs in this claim form. If you answered “NO” to question 1 OR question 2, you are not eligible to submit a claim. If you answered “YES” to questions 1 AND 2, please answer the following questions: (a) How much did you pay for parts and labor in connection with the replacement or repair? (You may not include any amounts paid for by Nissan or by an extended warranty or service contract provider). (b) What was your odometer mileage at the time of replacement or repair? $ miles (c) Do you have documentation showing that the replacement or repair was to the transmission assembly (including torque converter and/or valve body) or Automatic Transmission Control Unit (ATCU) in your vehicle? If yes, please include an original, or true and correct copy of documentation created by an authorized Nissan dealer or other non-Nissan automotive repair facility at or near the time of the replacement or repair, which includes the following information: