VEHICLE COMPONENT FAILURE / VEHICLE FIRE
Request for Analysis
All Components Analyses, Fire Origin & Cause, Mfg./Design Defects, EDR Download
Name of Insured:
First Name
Last Name
Name of Claimant:
First Name
Last Name
Claim Number:
Date and Time of Loss:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Your Name:
Mr.
Mrs.
Prefix
First Name
Last Name
Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Your Company Name:
Your Company Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please address report to:
Email:
example@example.com
Shipping Address (if different from above):
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Vehicle & Document Information:
Year, Make, Model:
Location Name:
License Plate:
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
VIN:
Contact:
Phone:
Please enter a valid phone number.
Format: (000) 000-0000.
Mileage:
Stock/Lot #:
Facility has been given authorization for Impact General's inspection:
Yes
No
Any recent repairs made?
Yes
No
If yes, explain:
Work Orders:
Enclosed herewith
Being sent
Requested
Not available
Documents Submitted:
Repair estimate
Photographs
Statement(s)
Police/Fire Report
Component Failure:
Loss Scenario:
Analysis Requested:
What did driver feel or observe prior to the accident?
Were there any warning lights on dash?
Yes
No
Explain:
Any vibration or abnormal noises?
Yes
No
Explain:
Brake Issue: What was the brake pedal feel?
Engine Failure: Describe failure (i e. smoke, smoke color, vibration, noise)
Steering Issue: Describe failure (i e. hard to steer, normal steer, no steer, vibration)
Tire Failure:
F/L
F/R
R/L
R/R
Tire Make:
Tire Model:
Fire Causation:
Loss Scenario:
Analysis Requested:
Was the vehicle parked?
Yes
No
How long before fire was noticed?
Were any warning lights on dash?
Yes
No
If yes, which ones?
Was the vehicle hard to steer?
Yes
No
If yes, explain:
Did the transmission shift okay prior to fire?
Yes
No
If no, explain:
Did the engine misfire or run rough?
Yes
No
If yes, explain:
What equipment was in use? (i e. radio, A/C, etc.)?
Was vehicle towing another vehicle/trailer?
Yes
No
Climbing a grade?
Yes
No
Where was smoke first noticed?
What color was the smoke?
Black
White
Gray
Other
Documents Submitted:
Recent repair orders
Service history
Scene photographs
Repair estimate
Vehicle photos
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