Let’s work together to find a solution

While the chances of damage occurring in any Soapy Sam's location are rare, it could sometimes happen. We have a damage claim form you can fill out to report damage to your vehicle. We also want to give you a friendly reminder to do the following lower power antennas, remove any other antennas, remove magnetic signs, remove balls or flags or any other decoration from the antenna, remove the trailer hitch, and your truck bed MUST be empty and clean prior to entering the car wash. This list is not all-inclusive.

Damage Claim Form

Prior to filling out the form, please read the following disclaimer:

We are responsible, except for the following: Antennas, Wiper Blades, Bug Shields, Previous Damage, Non-Factory Parts or Modifications, Chrome or Modling, Damage Due to Driver Error, and Pontiac Mirrors.

If you have questions, please give us a call at 574-314-6677.

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Driver's License Number

License Plate Number

Vehicle Make

Model

Year

Color

Mileage

Owner's name

Date Damage Occurred

YYYY

Time of Wash

Hour

Minute

Second

Location of Incident

Car Wash Location

Employee Present?

Yes

Did you speak to an employee?

Yes

Describe Vehicle Damage

Describe, in detail, how the incident occured, including whether the incident was machine related, a collision with a barrier, an incident with the cloth or some other type of incident

Please read and understand the following Certification before signing this form

I state that my answers on this form are true and correct to the best of my knowledge. I also understand that submitting this form does no indicate that Lighthouse Carwash has accepted responsibility for this matter, and that responsibility will be determined after further investigation and analysis of the facts and circumstances relating to the incident. I further understand and agree that I am providing the requested information voluntarily in order to assist the Lighthouse Carwash Company to investigate the incident, and that, by completing the claims form, I hereby grant my permission to the Lighthouse Carwash Company to the information contained herein and that this form and any additional information my be sent to Lighthouse Carwash Company's insurer or others investigation the incident.

I have read and I understand.

I have not read, and I do not understand.

Signature

Date

YYYY

Let’s work together to find a solution

Damage Claim Form

Info

Locations

Soapy Sam’s Car Wash