***NOTICE*** DO NOT USE THIS FORM
Please use our new form, found on our website. Link here: https://form.jotform.com/253514713355960
Adjuster's Contact Info:
Adjuster's Name
*
First Name
Last Name
Independent Adjusting Firm and Mailing Address
File Number
Insurance Company and Mailing Address
*
Insurance Co Claim Number
*
Adjuster's Phone Number
*
-
Area Code
Phone Number
Adjuster's E-mail Address
*
Item Description and Location:
Item to be Listed
*
ACV of Item Posted
Year/Make/Model
Serial Number
Odometer/Hours
Options and Features that will facilitate the sale of the item
*
Damage Description in as much detail as possible
*
Omissions and/or additions to the salvage that may or may not be seen in the photographs posted
*
A lien check must be conducted for all equipment and vehicles. Do you wish us to conduct a lien check on your behalf. (charge of $20) If no, please provide a copy by attaching it below.
*
Yes
No
Location of Salvage Item
*
Insured
Dealership
Restoration Company
Other
Name of dealership, contact name, phone number and email address. Name of insured (for reference).
*
Name of restoration company, contact name, phone number and email address. Name of insured (for reference).
*
Contact info for the insured, including name, town/city, phone number and email address.
*
Location including contact name, town/city, phone number and email address. Name of insured (for reference).
*
Is the salvage item accruing storage charges at this time?
*
Yes
No
Once sale is finalized do you want Barga.ca to pay the storage charges on your behalf
*
Yes
No
Bid Requirements
*PLEASE NOTE: If no reserve bid is chosen, you are authorizing Barga Insurance Salvage to sell to the highest bidder.
Reserve Bid
*
Yes (reserve bid should be starting bid)
No
Amount of Reserve Bid
Additional Comments
Upload salvage photos
Upload a File
Cancel
of
Upload damage repair estimate and any other pertinent documents such as: Lien Check, Valuation Report, Authenticity Certificate etc.
Upload a File
Cancel
of
Submit
Print Form
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