Contact Information:
* Name:
* E-Mail:
* Phone (Day):
Phone (Eve):
Address:
City:		Zip:
State:	Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington D.C. West Virginia Wisconsin Wyoming
* Please enter at least one phone contact.
Vehicle Information:
Year & Make:	Select Year 2010 2009 2008 2007 2006 2005 2004 2003 2002 or Older / Select Make Acura Audi BMW Buick Cadillac Chevrolet Chrysler Daewoo Dodge Eagle Ford GMC Honda Hyundai Infiniti Isuzu Jaguar Jeep Kia Land Rover Lexus Lincoln Mazda Mercedes Mercury Mitsubishi Nissan Oldsmobile Plymouth Pontiac Porsche Saab Saturn Subaru Suzuki Toyota Volkswagon Volvo
Model:		Current Mileage:
New/Lease/ Used ?	Select Purchase Type New Used Demo Leased	Date of Purchase:
Warranty Type:	Select Warranty Type New Car Warranty Extended Warranty Service Contract Dealer Warranty No Warranty - "AS-IS"

Defect and Repair Information:
Complaint / Defect	# of repair attempts	Does the problem still exist?
Engine, Transmission	0 1 2 3 4 5 +
Brakes	0 1 2 3 4 5 +
Steering & Suspension	0 1 2 3 4 5 +
Electrical System	0 1 2 3 4 5 +
Body, Paint & Interior	0 1 2 3 4 5 +
Heating/ AC	0 1 2 3 4 5 +
Leaks	0 1 2 3 4 5 +
Noises	0 1 2 3 4 5 +
	0 1 2 3 4 5 +

The total number of days the vehicle has been in the shop for all problems:    Select 0-15 16-29 30-45 Over 45

Comments / Additional information:

How did you hear about us? Select National Lemon Law Center Lemon Law America Lemon Law.com Yahoo! Google MSN AOL DMV.org Other Internet Site TV/Radio Friend/Relative Other

DISCLAIMER: By submitting this form, I understand that I am not entering into any attorney-client relationship with Alex Simanovsky & Associates. This is merely a request for information. No representation shall be undertaken without a written terms of representation.

*When we say "FREE TO THE CONSUMER" we mean exactly that! While we don't work for free, consumers will not be charged any attorney's fees. We seek to recover our attorney's fees from the manufacturer and/or dealer pursuant to State and Federal Laws.