Total Loss Vehicle Appraisal Order Form | Collision Claim Associates, Inc.

Vehicle Owner Information

Name*

Email Address*

Primary Phone*

Alternate Phone

Cell Phone*

Home Address*

Street Address City State ZIP Code

Name of Your Insurance Company:*

If other party at-fault, enter name of their Insurance company

Vehicle Inspection Location

Please provide us with the location where your vehicle can be inspected. Inspections are completed Monday – Friday between the hours of 8:00am and 5:00pm. Specific times are not given due to the uncertainty of traffic and other delays. You may select a day part.

Location:*

Residence Address As Above
Body Shop / Salvage Yard

Salvage Yard Lot #*

Name of Location:*

Phone Number*

Contact Name*

Address*

Street Address City State ZIP Code

Vehicle Information

Year*

Make*

Model*

Series/Package (i.e.: LS, ES, XLT, GL)*

Color*

# of Doors:*

VIN Number:*

Engine Size*

# of Cylinders

Hidden

# Of Cylinders*

Engine Type*

Hidden

Engine Type*

Gas
Diesel
Hybrid
Turbo

Drive Train*

Transmission*

Hidden

Transmission*

Mileage at time of Damage:*

Date Of Current Damage/Collision:*

Any Prior Collision?*

(If Yes) Give Date

Pre-Damage Vehicle Condition:*

Cost of Repairs $

If the vehicle is less than 1 year old, what was the purchase price $:

Cash Price Not including trade allowance, sales tax, warrantees or finance charges

Vehicle Options (Please check all that apply)

POWER ACC

RADIOS/ALARMS

SEATS

PAINT/TRM/GLASS

Two-Tone
Special Paint
Metallic Paint
Graphics
Tinted Glass
Tinted A/M
Privacy Glass
Sunscreen Glass
Rear Spoiler

ROOF

Landau Roof
Hard top
Luggage Rack
Roll/Light Bar
Pwr Conv Top
Soft Top

SUNROOF

Pwr Solid Sunroof
Manual Solid Snrf
Pwr Glass Mnroof
Pop-Up Roof
T-Top Glass
T-Top Solid
Dual Sunroofs

PICKUP TRUCK/VAN

Bed Size

Please specify bed size below

BUMPERS

Rear Stp Bumper
Tubular Bumper
Chrome Bumpers
Chrome Stp Bmpr

WHEELS/TIRES

OTHER

Lift Kit (

Please specify size in inches below

Lowered

Please specify size below

Notes

Additional Information

Terms Agreement*

I have read and fully understand both the Service Agreement & the website Terms Of Use

Terms of Use

Phone

This field is for validation purposes and should be left unchanged.