Consumer Mediation Services - Mediation Request Form

To avoid timeouts/errors, please gather the following information PRIOR to completing this form. Please note, basic contact info is required, while all remaining items are useful in assisting you, they are optional. Thank you!

  • Basic contact info
  • Vehicle make, model, year + current mileage
  • Date of purchase/lease + type of warranty
  • Selling dealer contact info
  • Servicing dealer contact info
  • Summary of your complaint details
  • Summary of resolution you are seeking
Contact Information - Step 1 of 6

Please enter your contact information. Fields with '*' are required entries.

*First Name: 

MI: 

*Last Name: 

*Address:     

*City: 

*State:  

*Zip Code: 

*Telephone #:  

*How did you hear about us?
*Email: 
*Confirm Email: 

Click "Continue" to go the next step