Specialty Automobile Electronic Valuation Request Form

888.475.9975 phone

888.475.9935 fax

www.v-v-s.com web

file submit and inquiries

Specialty Automobile Electronic Valuation Request Form

Instructions: Within the Electronic VRF use the Tab key NOT the return/enter key. To indicate if an option is present and a check box is used either click the box with your mouse or Tab to it and hit X or the space bar. If unable to fill out any particular section try going to prior section by hitting Shift-Tab and then returning by hitting Tab. Within freeform fields abbreviate if needed. When completed “Save As” your Claim Number or Insured Name, note where file was saved and submit as an attachment to . Attach any other pertinent document with submission. Call 888.475.9975 for assistance.

Office ID or Name and City

Office Phone Number VVS Request # if already exists

Claim Rep Name Claim Number

Office Fax Number Email Address

Date of Loss Type of Loss

Appraiser Company Name Appraiser Phone

Appraiser Name ACV Amount

Owners Name Contact Name

City State

Owners Phone(required if no zip) Owners Zip Code

Vehicle Information

VIN

Year Make Model

Body Style Select One2 Door4 DoorPolice CarTaxi CabLimousineOther Engine Trans Select OneAutomatic3 Speed4 Speed5 Speed6 SpeedAutoStick

Overdrive 4 X 4 AWD

Description of Vehicle (if needed):

Options and Equipment

Power Steering Power Brakes Power Windows Power Locks

Power Drvr Seat Power Pass Seat Power Mirrors Power Antenna

Power Trunk Rear Wipers Headlight Washers Heated Mirrors

Lthr Steering Whl Wood Grain Towing Equipment NoneBumper HitchClass III HitchClass IV HitchReese HitchFull Package

Air Conditioning Rear AC Rear Defroster Tilt Wheel

Telescopic Wheel Cruise Control Intermittent Wipers Auto Load Levelers

Radio Select OneAM onlyAM/FMStereoST/CassetteST/CDNoneUnknown Premium Sound Compact Disc NoneCD PlayerCD Changer CB Radio

Integrated Phone Keyless Entry Reclining Seats Heated Seats

Tinted Glass NoneDeep Interior Trim Select OneClothLeatherVelourVinyl Factory Wheels Wheel Type Select OneAlloyAluminumChromeWheel CoversSimulatorsStyled SteelWire WheelsN/AOther

Seating Select OneBenchSplit BenchBuckets Third Seat Paint Select OneMetallicStandardTwo ToneMulti ToneRoof Type Select OneNoneFlip RoofManual GlassManual SteelElectric GlassElectric SteelT TopsGlass T TopsConvertibleVinyl Roof

Spoiler Select OneNoneFrontRearFull Package Theft Deterrent Disc Brakes Select OneNoneFour WhlTwo WhlABS Select OneNoneTwo WheelFour Wheel

Air Bags Select OneDriver OnlyDrv/PassD/Pass/SideD/P/S/RearNone Traction Control Fog Lights Sentinel Lighting

Limited Slip ODOMETER

Police Car / Taxi Cab Options

2 Way Radio Divider Dual Spot Light Gun Rack

Light Bar Siren Spot Light Flashers

Limousine Options

Limousine Make Limousine Model

Double Cut Partition VCR Rear Radio

Rear CD Player Dual Battery Dual Cell Phones Dual AC

Dual Axle Dual Partition Electric Bar Extended Doors

Intercom Jacuzzi Widebody

Stretch Length - - - Select One325054566065667075858890100110120130140150160170180200”

Other Items:

Specialty Automobile Electronic Valuation Request Form

Specialty Automobile Conditions

Seats Cond 3 Average1 Excellent2 Above Average4 Below Average5 Poor Dash Cond 3 Average1 Excellent2 Above Average4 Below Average5 Poor Carpet Cond 3 Average1 Excellent2 Above Average4 Below Average5 Poor

Headliner Cond 3 Average1 Excellent2 Above Average4 Below Average5 Poor Engine Cond 3 Average1 Excellent2 Above Average4 Below Average5 Poor Trans Cond 3 Average1 Excellent2 Above Average4 Below Average5 Poor

Body Cond 3 Average1 Excellent2 Above Average4 Below Average5 Poor Paint Cond 3 Average1 Excellent2 Above Average4 Below Average5 Poor Glass Cond 3 Average1 Excellent2 Above Average4 Below Average5 Poor

Tires - - - Front Wear Remaining % Rear Wear Remaining %

Refurbishments: Type of Refurb Date and/or Cost of Refurb

Indicate here if a call prior to valuation being completed is needed or any other comments -Thank you:

When completed “Save As” your Claim Number or Insured Name, note where file was saved and submit as an attachment to .