YOUR PERSONAL INFORMATION:

TODAY'S DATE:

**First Name: **Last Name: **Address: **City: **State: **Zip: **E-Mail: **Work Phone: EXT:  **Home Phone: Cell Phone: Best time to call: NO PREFERENCE9:00 AM - 10:00 AM10:00 AM - 11:00 AM11:00 AM - NOONNOON - 1:00 PM1:00 PM - 2:00 PM2:00 PM - 3:00 PM4:00 PM - 5:00 PM Pager: Fax Number:   **Preferred mode of contact: WORK PHONEHOME PHONECELL PHONEE-MAILPAGERFAX

**Are you the registered owner of the vehicle? YES NO If "NO" please give Owner's Name:

Is the vehicle treated with a paint protectant?YES NO

**In your opinion, is your vehicle safe to drive?YES NO

If your answer is "NO" please explain why:

If Insurance Company, which one:	CSAA ALLSTATEMERCURY STATE FARMFARMERSOTHER
If "OTHER" insurance company give name:
Whose insurance company?	MY INSURANCE CO.THEIR INSURANCE CO.OTHER

Adjuster's Name:
Adjuster's Phone:		EXT:
Your Insurance Agent's Name:
Date of Accident:		JANUARYFEBRUARYMARCHAPRILMAYJUNEJULYAUGUSTSEPTEMBEROCTOBERNOVEMBERDECEMBER12345678910111213141516171819202122232425262728293031  YEAR:
**Do you know the Claim Number?		YES NO
If "Yes" what is it?
Policy No:
Has liability been determined?		YESNODON'T KNOW
Deductible Amount:		$WAIVED? YESNODON'T KNOW

Have you gotten other estimates?		YES NO
If yes, how many?		One Two Three Four 5+
How did you hear about our company?		Insurance ReferralAgent Referral Customer Referral Repeat Customer Phone Book Radio Spot Other
Do you plan on setting up an appointment for the repairs?		YES NO
Will you need a rental?		YES NO
Would you need a ride when you drop off your car for repairs?		YES NO
Would you like us to fax your estimate?		YES NO

When scheduling appointments please note that the time required to complete the "damage report" of your vehicle is approximately 30-60 minutes.  Initiating the claims handling process requires digital pictures of the damage, and a computerized "visual damage inspection" report (specific to your insurance company's requirements).  We then up-load the data with your Claim File to the insurance company for expedient approval. 

When noting your preferences be sure to allocate sufficient time.

Please indicate your preferences for appointment scheduling. WeekdaysMorning Afternoon Anytime Saturdays Morning Afternoon Anytime Special Requests or Comments: