Name
*
Address
*
City
*
State
*
Zip Code
*
Email Address
*
Telephone (add extension if applicable)
*
Alternate Telephone
Best Time to Reach
Type of Appraisal
*
Diminished Value
Total Loss
Bank Loan
Actual Cash Value
Pre-Purchase Inspection
Damage Estimate
Umpire
Crash Data Retrieval – CDR
Auto Accident Reconstruction
Insurance Fraud Investigation
Court Expert Witness
IF DIMINISHED VALUE:
If diminished value, any prior accidents?
If there was a prior accident, what was the date?
Total diminished loss repair bill.
IF TOTAL LOSS:
Miles at time of loss.
If total loss, what was the insurer's offer?
Date of Loss
Year of Vehicle
*
Vehicle Make
*
Model of Vehicle
*
Miles at time of loss.
VIN#
*
Repair Bill Total
*
Are repairs complete?
Yes
No
Name of at-fault insurance company.
Claim Number
Insurance Adjuster Name or Team Number
Adjuster's Phone Number (Extension if Applicable)
Adjuster's Email
Name of Your Insurance Company
Claim Number
Type of Coverage
Full Coverage
Liability
Uninsured Motorist
No Insurance
I don't know
Do you have a copy of the repair estimate?
Yes
No
Comments - Tell us what happened.
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