1

Your Name* This field is required.

First Name

Last Name

2

Name

3

Your Phone Number* This field is required.

4

Your Email Address* This field is required.

5

If you need to save this form and come back to it later, click "Save" directly under the survey. You will receive an email with a link to return to this form and continue.

6

What service are you contacting Prime for?* This field is required.Auto Damage Estimating, or Umpiring

7

Please elaborate* This field is required.

8

If you are looking for Diminished Value services, please fill out the form on our Diminished Value page for more information and to find the appropriate intake form.

Please reach out to us at contact@prime-ri.com with any questions.

9

Are you filling out this form on your own behalf or on behalf of a customer?* This field is required.

Me

Customer

10

Customer's Name* This field is required.

First Name

Last Name

11

Customer's Phone Number* This field is required.

12

Customer's Email Address* This field is required.

13

The Assignment of Rights form is what allows Prime to act on behalf of an insured or claimant regarding damages to their vehicle. It must be completed for Prime to move forward after reviewing the intake information provided with this form.

If it has not been completed, please find the link below:

Assignment of Rights form

https://form.jotform.com/253315663736057

*We will not be able to move forward with this case until the form has been completed and submitted to us. If you have any questions, please reach out to us at: RTA@prime-ri.com.

14

Has the Assignment of Rights form been completed?* This field is required.

Yes

No*

15

Location of Vehicle* This field is required.

Shop Name, if applicable

Street Address

City

State / Province

Postal / Zip Code

Country

16

What year is the vehicle?* This field is required.

17

VIN* This field is required.The VIN is on your repair invoice and on the sticker inside your driver's side door.

18

Has the vehicle been in any prior motor vehicle accidents?* This field is required.

Yes

No

Other

19

Please detail any unrelated damages still present on vehicle.

20

Insurance Company* This field is required.If you were not the at-fault party, please indicate the responsible party's insurance company. If you do not have this information, put NA.

21

Named Insured on Policy

22

Claim Number* This field is required.

Also referred to as File Number

23

Name of Insurance Company Adjuster/Contact*If you provide the contact information for the claim adjuster assigned to this claim, we will reach out on your behalf.

24

Insurance Company Adjuster/Contact Email Address

25

When was the accident?* This field is required.The date should be located on your vehicle repair invoice if you do not remember.

Date

26

Where did the accident occur?* This field is required.

Rhode Island

Massachussetts

Other

27

Location of related damages* This field is required.

Front

Rear

Left Side

Right Side

28

Has the insurance company assigned an appraiser yet?* This field is required.

Yes

No*

Unsure*

29

Insurance's Chosen Appraiser's Name

30

Insurance's Chosen Appraiser's Contact Email Address

31

Insurance's Final Estimate Total** This field is required.This information is needed to determine who owes our fees.

*Prior to RTA Invocation

32

Copy of Final Insurance Estimate

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Please note: If you do not currently have any estimate copies, add them to this form as soon as you obtain them. We will send an update link after review.

33

Insurance's Chosen Appraiser's RTA Settlement Proposal* This field is required.

34

Copy of Insurance RTA Settlement ProposalIf you do not currently have this document, please forward it to us at your earliest convenience, as we cannot move forward without it: RTA@prime-ri.com.

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35

Your Chosen Appraiser's Name* This field is required.

The appraiser you chose for the RTA process.

36

Name of Your Customer's Chosen Appraiser* This field is required.

37

Your Appraiser's Contact Email* This field is required.

38

Your Appraiser's RTA Settlement Proposal* This field is required.

39

Your Appraiser's RTA Settlement ProposalIf you do not currently have this document, please forward it to us at your earliest convenience, as we cannot move forward without it: RTA@prime-ri.com.

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40

Where the vehicle was repaired.

Submitted through a unique QR code.

41

Upload applicable statutes or supporting documentation you'd like me to review:

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42

Upload applicable photos

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Please note: If you do not currently have any photos, add them to this form as soon as you obtain them. We will send an update link after review.

43

Final File UploadAny additional documentation you'd like to provide

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44

Any other details:Skip if there are no other details you'd like to share

45

Right to Appraisal Intake Form

If you are looking for Diminished Value services, please fill out the form on our Diminished Value page for more information and to find the appropriate intake form.

The Assignment of Rights form is what allows Prime to act on behalf of an insured or claimant regarding damages to their vehicle. It must be completed for Prime to move forward after reviewing the intake information provided with this form.

Assignment of Rights form

You can now submit the form