Vehicle Appraisal Request Form

Company Information

Insurance company :

Address :

Adjuster : Phone : Fax :

Email : Claim No. :

Vehicle Owner Information

Name :

Address :

City : State : Zip code :

Email :

H. Phone : W. Phone :

Person To Contact : Where To Contact ? When ?

Policy Information

Bodily Injury : Property Damage :

Single Limit : Other Coverage & Deductibles :

OTC Ded. : Loss Payee :
(UM, no fault, towing etc)

Collision Deductible :

Insured Vehicle

Year, Make, Model : Vehicle Identification No. :

License Plate No. : Owners Name :

Owners Address : Owners Phone :

Describe Damage :

Estimate Amount $ : Where Can Vehicle Be Seen ?

When ? Other Insurance on Vehicle :

Property Damage

Describe Property :
(if auto - make, year, model, Plate no.)

Vehicle / Property Insurance :

Company / Agency Name & Policy # :

Owner Name : Owners Address :

Bus. Phone : Res. Phone :

Describe Damage :

Estimate Amount $ : Where Can Damage Be Seen ?

Reported By : Reported To :