All required fields are marked with *
CLAIM INFORMATION
Mileage:*
R.O.#*
R.O. Date:*
CUSTOMER / FACILITY INFORMATION
Customer Name:*
Customer Phone:
Policy #
Repair Facility:*
Repair Phone:*
Repair Fax:
Email for Claim Reply:*
VIN #*
Year/Make/Model:
Customer Complaint:
Repairs Required:
PARTS
QTY*
Part Number*
Description*
Ea.*
Total*
LABOR
Operation
Hours*
Rate*
VENDOR SUBLETS
Vendor
Invoice #
Invoice Amount
Total Sublet
TOWING, TAXES, RENTAL, TOTALS
Towing
Sub-Total
Policy Deductible
Taxes*
Parts:*YesNo Labor:*YesNo
Total Tax
Rental Car
Total Rental
Claim Total
