Today's Date

Policy Number

Claim Number

Date of Loss

Endorsement 43R ?

 Yes         No

Deductible (please check one)

 None    $250    $500    Other* (see below)

*If "other" please enter deductible amount

Insured pays GST?

  Yes           No

Type of Loss

 Collision         Liability         Comprehensive

Insurer

Adjuster

Phone Number

Fax Number

Owner Name

Home Phone

Business Phone

Residence or Business Address

Vehicle Year, Make, Model, Color

License Number

VIN

Area of Damage

Shop Name

Phone

Address

Major Intersection

Comments

Sender's Name

Sender's Email

BEFORE you submit this form to the Alliance Appraisal Group, you may wish to print a copy for your file purposes by clicking the PRINTER icon at the top of your browser window, or by clicking File>Print>OK. This printout will require two letter-size pages.