Please read the following statements carefully, as a claim will not be processed unless initials from the claimant / service advisor have been provided.

Please type your initials to indicate: I am aware that Eckbond Inc. relies on the information and statements above. I hereby certify that the above statements are complete and accurate to the best of my knowledge. I understand that any inaccurate information entered on this form could affect the outcome of the claim, including denial of claim.