CLIENT INFORMATION FORM
Thank you for your interest in our services; we look forward to assisting you.
Please complete the following as thoroughly as possible so we may do so.
Contact Information:
Prefix:
Mr.
Mrs.
Ms.
Name
Street address
City
State
Zip Code
EMAIL
*
Cell Number
Second Phone Number
Preferred Contact Method
Phone
E-mail
Other
How Did You Hear About Us?:
Type of Service Needed
Diminished Value
Pre-Purchase Inspection
Post Repair Inspection
Total Loss Appraisal
Consultation
Auto Value Appraisal
Other
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Vehicle Information
VIN#
*
Year
Make
Model
Trim Level
2 Door or 4 Door
Body Style
Color
Mileage
License Plate #
Purchased
New
Used
Purchase Price
Purchase Date
Is Vehicle a Lease?
Yes
No
Purchased from?
Factory or Aftermarket Options-Accessories?
Any Previous Damages or Losses?
*
Yes
No
Unknown
Other
If Yes When and How Much?
Airbag(s) Deployed?
Yes
No
How Many Occupants Were In the Vehicle During The Loss
Was anyone injured during the loss?
Yes
No
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Insurance Claim Information
Insurance Company
Claim Number
Claim Representative
Phone Number
State Loss Occurred?
Date of Loss
-
Month
-
Day
Year
Date
Insurance Co.
Your insurance co.
At Fault Party's ins. co.
Other
Insurance Comp. Original Offer
For diminished value or appraisal
Estimated Repair Cost
Have Repairs Been Completed?
Yes
No
Other
Repair Facility's Name
Repair Facility's Address
Estimator's Name
Phone Number
Repairer's Email
How Would You Rate Your Satisfaction With the Performed Repairs?
Rows
Poor
Average
Good
Very Good
Excellent
Quality of Repairs
Customer Service
What, if Any, Concerns Do You Have With the Repair
By my signature below I affirm the above information is correct and accurate to the best of my knowledge and recollection.
Please Attach a Copy of the Estimate of Repair
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Photos or Other Docs
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