Co-Op Claim Form

To submit a claim, send:
•  A printout of this completed form
•  A copy of your pre-approval form
•  Third-party invoices
•  Proof of performance (copies of ads, flyers, event photos, etc.)

to:
Delphi Corporation
Attn: Co-Op Administrator
5820 Delphi Drive, Building D
MC: 480-405-311
Troy, MI 48098-2819 USA

 
Customer Number:
Claim Number:
Company Name:
Customer Name:
Address:
City:
State/Province:
ZIP/Postal Code:
Country:
Phone:
Fax:
E-mail:
Key Contact Person:
Key Contact E-mail:
Date:
 
Program Description:
 
Purpose of Advertisement
and/or Promotion:
 
Target Audience:
 

Target Media:
(Please check the appropriate
box or detail under “Other”)











 
Final Program Cost:
  Include invoice from agency/supplier.
 
Promotional Period:
  Provide start and end dates of promotion.
 
Creative/Layout: Include copy of affidavit, tear sheet, photo, pdf file, etc.

Note: Claims will be reviewed and processed for credit within 4-6 weeks. Delphi reserves the right to deny all claims.

For final claims submission, mail claim to:
Delphi Corporation
Attn: Co-Op Administrator
5820 Delphi Drive, Building D
MC: 480-405-311
Troy, MI 48098-2819 USA