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DVCHECK
Vehicle Owner's Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Type of Claim
*
Please Select
Diminished Value
Total Loss
Vehicle Year
*
Vehicle Make
*
Vehicle Model
*
Vehicle Trim Level (SE, XLT, LE, Base, etc)
*
Approximate mileage on accident date
*
Date of Accident
*
-
Month
-
Day
Year
Date
State where the accident happened
*
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
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
West Virginia
Wisconsin
Wyoming
Estimated repair costs
*
Any prior accidents or repairs?
*
Yes
No
If yes, estimated repair cost of the previous accident
Are you leasing your vehicle? (Vehicle will be turned back in on a set date)
*
Yes
No
How much is your current settlement offer? (For diminished value or total loss)
*
Name of your insurance company?
*
Name of at-fault insurance company?
*
Source
Please Select
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