Simplicity7 Intake Form
Name
*
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Year, Make and Model of Car.
Vehicles Vin
What Insurance do you have?
What insurance does the other party have?
What was the Date of the accident?
*
Was the Vehicle Towed in?
*
What was the date of Tow-in?
Have you made a claim yet?... If Yes, what's your claim number?
*
A brief description of the accident.
*
By accepting below, I authorize Simplicity7 Autobody to perform the repairs and services necessary on my vehicle as outlined in the work order. I understand that any additional repairs or services will require my approval before proceeding. I acknowledge that I am responsible for the payment of all services rendered, including any parts and labor, and that Simplicity7 Autobody is not responsible for any pre-existing damages or theft of personal items left in the vehicle. I also authorize the movement and handling of my vehicle as required for the completion of the work. You hereby authorize your insurance agency, to pay simplicity7 to complete all necessary work.
*
I Accept with the terms and agreements.
Submit
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