Report Retrieval Method

/ Email / Fax / Other (Specify):
Claim Representative Name: / Claim Representative Email: / Claim Representative Contact #:
( ) -
Date of Loss (mm/dd/yyyy): / Claim #: / Policy #: / Type of Loss:CollisionTheftOther
Insured Name: / Insured Phone #: / Claimant Name: / Claimant Phone #:
Loss State: / Loss Zip Code:
VIN:

Year:

/ Make: /

Model:

Trailer Type:
FlatbedStakebedCar Hauler (Open)Car Hauler (Enclosed)Dry VanRefrigerated VanEnclosed UtilityHorse/LivestockV-DeckMotorcycleLow BoyTankLandscapeDumpSnowmobileATVBoatTilt DeckPersonal WatercraftCurtain sideWalking FloorDrop deck FlatbedDrop frame(moving van)Utility bed
Hitch Type:
Goose neckBumper pullPintleKing PinHydraulic goose neck
Lift Gate: Yes No
Manufacturer:______
Lift Gate Year______
Capacity______(lbs) / Exterior Construction:
Frame:
SteelAluminumOther
Other: ______
Deck:
SteelAluminumSteel RailDiamond PlateWoodOther
Other: ______
Sides:
SteelAluminumWoodFiberglassOther
Other: ______
Roof:
SteelAluminumWoodTranslucentOther
Other: ______ / Length: ______(ft)
Height: ______(ft)
Width: ______(in)
Interior Lining:
Plywood
Kemlite None
Insulated:
Yes No
Side Door Type:
SwingRollupCurbsideRampRoadsideOther
Other______ / Side Door Type:
SwingRollupCurbsideRampRoadsideOther
Other______
Rear Door Type:
SwingRampRollupOther
Other______
Axles:
Sliding: Yes No
*# of Axles_____
*Axle Capacity__ (lbs)
Tire Size:______
% of wear remaining___%
Outside Wheel:
SpokeAluminumAluminum DiscCustomOther
Other______
Inside Wheel:
SpokeAluminumAluminum DiscCustomOther
Other______ / Suspension:
Air RideSpringTorsion BarOther
Other______
Brakes:
ElectricSurgeAirOther
Other______/ Options:
Interior Lighting
Shelving
Tool Box
Tongue Jack
Roof Vent
Cabinets
Work Bench
Manual Tarp
Fenders
Slush Guard /

Options:

Tie Down
Ramp
V-Nose
Spare Tire
Beaver tail
Stone Guard
Electric Tarp
Slush Guard

Horse/Livestock:

Horse Trailer
Sheep Trailer
Hog Trailer
Cattle Trailer
Other Livestock Trailer
Enclosed: Yes No
# of Horses______
Load Type:
Slant Straight
Living Quarters: Yes No
Manufacturer: ______
Length of Quarters: ______(ft)
Options:
Feed Mangers
Hay Rack
Saddle Rack
Tack Room
Dressing Room
Dividers
Walking Floor /

Dump:

Belly
Side
End
Transfer
Liner Type
Plastic Steel
Air Dump Gate
Heated
Coal door
Vibratory

Tanker

Water Chemical
Food Fuel
Waste Other______
# of Compartments______
Capacity______(gal)
Pump System Yes No
Pump Manufacturer______
Model #______/

Refrigerated

Cooling Unit Manufacturer
______
Model #: ______
Year:______
Hours:______
Overhaul
Date: ______
Price______

Snowmobile/Jet Ski

Flatbed V-nose
Flatbed with cap
Enclosed
Slush guard
Tool box
Number of units rried______

Car hauler:

Number of units:______

Overall Condition Rating

/ (1) Below Average / (2) Average / (3) Exceptional

Additional Equipment (include price if applicable):

Pre Tax Adjustment: / Add: / Deduct:
Pre Tax Adjustment: / Add: / Deduct:
Sales Tax %: / Deductible:
Post Tax Adjustment: / Add: / Deduct:
Post Tax Adjustment: / Add: / Deduct:
Notes