Please fill out this form with brief description of your appraisal request or claim information with your inquiry.
Claim # *
Date Assigned *
Date of Loss *
Independent Adjusting Company *
Mailing Address *
City *
Province *
Postal Code *
Direct Phone *
Fax
E-Mail *
Please Inspect *InsuredThird Party
Insured Name *
Insured Home Phone *
Insured Work Phone *
Third Party Name
Third Party Home Phone
Third Party Work Phone
Vehicle Description (Year, Make, Model) *
Location (Shop, Tow Yard, etc) *
Serial Number *
Colour *
License *
"WOP" *YESNO
OK To Release To Owner Or Shop? *YESNO
Damage Description *
Confirm Animal Impact
Confirm Hit And Run Damage
Please Confirm Number of Occurrences
Please Complete Auto Source if TL
Please arrange For Towing
Please call back with quote for inspection
Do Not Release Appraisal to Owner or Shop
Low Impact Report Required
Please remove salvage to
Misc Details