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Vehicle Damage to Property - Evidence Gather Form
Please complete this form to document the vehicle information so we can get your money back from the drivers insurance, etc.
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1
Company Name
*
This field is required.
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2
Your Name
*
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First Name
Last Name
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3
Date of Incident
*
This field is required.
-
Date
Year
Month
Day
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4
Claims Contact's Email Address
*
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example@example.com
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5
Location Number or Store Number
*
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6
Picture of Drivers License
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7
Picture of Insurance Card
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Max. file size
: 10.6MB
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8
Picture of Damage
You can add up to 6 photos
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9
Other relevant photos
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10
Tag Number, Make, Model, Name of Insurance Company, Policy Number
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11
Damage(s) Description
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