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Date:
Location:
Cause
Mechanical Breakdown (please specify):
Other (please specify):
7. “i have completed this form and certify that the information provided is complete and accurate.”
Signature of owner
Date
8. Sign and mail this completed form with original receipts to:
Suzuki Secure Advantage Roadside Assistance
P.O. Box 190, 135 West Beaver Creek, Richmond Hill, ON L4B 4R5
Name
Prov
Postal Code
Address
City
Business Phone
Extension
5. Details of your vehicle Disablement
6. Make Cheque Payable To (if Different from owner):
