March 10, 2010
Independent Insurance Appraisal Professionals
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(719) 660-9660
Please complete the form below to send an assignment to Advantage Services.
All fields marked with
*
are required.
Insurance Company Information
Company Name:
*
REQUIRED
Address:
*
REQUIRED
City, ST, Zip Code:
*
AL
AK
AR
AZ
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
REQUIRED
Adjuster Name:
*
REQUIRED
Adjuster Email:
*
REQUIRED
INVALID
Phone Number:
*
ext.
REQUIRED
Fax Number:
Claim Information
Insured
Claimant
Insured Name:
*
REQUIRED
Claim Number:
*
REQUIRED
Type of Loss:
*
Collision
Property
Comprehensive
Theft
Other
Date of Loss:
*
REQUIRED
Deductible:
Assignment Information
Type of Appraisal:
*
Auto/Truck
Motorcycle
Motorhome/RV
Heavy Equipment
Residential Property
Commericial Property
Other
Type of Assignment:
*
Full Appraisal
Photos only
ACV only
Other Assignment
Appraisal Delivery:
*
Full Appraisal via Claim Access
Full Appraisal via Email
Fax Appraisal and Email Photos
OTHER - specify below
Special Instructions:
Vehicle Information
VIN:
Year, Make, Model:
*
REQUIRED
License Plate:
Color:
Black
Blue
Brown
Green
Red
Silver
Tan
White
Yellow
Other
Point(s) of Impact:
*
Use Ctrl to select
multiple impact points
Front Center
Right Front Corner
Right Front Pillar
Right Side
Right Rear Pillar
Right Rear Corner
Right Rear Center
Left Rear Corner
Left Rear Pillar
Left Side
Left Front Pillar
Left Front Corner
Rollover
Undercarriage
Non-Collision
Unknown
REQUIRED
Total Loss Procedure:
*
Contact Adjuster
Evaluation - specify below
Salvage Bids
Evaluation and Salvage Bids
Additional Information:
Owner Information
Name:
*
REQUIRED
Address:
*
REQUIRED
City, ST, Zip Code:
*
CO
KS
NE
NM
OK
REQUIRED
Email:
INVALID
Primary Phone:
*
REQUIRED
Secondary Phone:
Alternate Phone:
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