Travel Trailer, 5th Wheel, Shamrock Prior Authorization Request Form
See flat rate manual to determine if this PAR is required. If required, fill out this form completely and fax to (574) 642-4999. If not, send the coded claim with parts to our Millersburg, IN facility for processing.
Date _________________________
Dealer Name _________________________ Dealer Number ________________________
Dealer Fax ___________________________ Dealer Phone _________________________
Customer Name ____________________________ Date of Purchase _________________
Model ____________________________________ Last 7 Digits of Serial # ____________
In the following space describe the problem:
In the following space describe the repair:
Time requested by dealer to complete repair_______________________
Authorization # ________________________ Time Authorized _______________________
Authorized by _________________________ Denied by ____________________________
Date ________________________________