Recreational Vehicle Electronic Valuation Request Form

888.475.9975 phone

888.475.9935 fax

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Recreational Vehicle 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 NumberVVS Request # if already exists

Claim Rep NameClaim Number

Office Fax NumberEmail Address

Date of LossType of Loss

Appraiser Company NameAppraiser Phone

Appraiser NameACV Amount

Owners NameContact Name

CityState

Owners Phone(required if no zip)Owners Zip Code

Vehicle Information

HIN

Year Make Model

Length# of AxlesSelect One0123456

Body TypeSelect OneCamper VanTravel Trailer5th Wheel TrailerPop Up CamperMini Motor HomeMicro Mini Motor HomeMotor HomeMotor CoachSlide On CamperUnknownClassSelect OneACT - TrailerN/AUnknown

Chassis Year Chassis Mfgr Chassis Model

Engine Mfgr Engine Mdl Transmission Select OneAutomatic3 Speed4 Speed5 Speed6 Speed9 Speed15 SpeedN/A

Description of Recreational Vehicle (if needed):

Options and Equipment

Power Steering Power Brakes Power Windows Power Driver Seat

Power Pass SeatAir ConditioningTilt WheelCruise Control

Radio Select OneAM onlyAM/FMStereoST/CassetteST/CDNoneUnknownPremium SoundCompact DiscNoneCD PlayerCD ChangerCB Radio

Captain Chairs No. or ChairsInterior TrimSelect ClothLeatherVinylWheel Type Select OneAlloyAluminumChromeWheel CoversSimulatorsStyled SteelWire WheelsN/AOther

Paint TypeSelect OneMetallicStandardTwo ToneTowing EquipNoneHitchTow PkgAnti Lock BrakesNoneTwo WhlFour WhlSuspension Select OneAir RideSpringNoneN/A

Aux Fuel TankRadar DetectorAlarm Odometer

Dual RadioHeadphone JacksColor TVVCR

Central VacuumIce BoxMicrowavePower Sofa Bed

Porta PottySolar PanelsStorage PodSatellite Dish

Luggage RackFloor PlanKitchenSelect FullHalfNoneOtherBath Select OneFullHalfNone

AwningsSlide Out Rooms Power Slide Length

Outside ShowerGeneratorNone2.5KW3.0KW3.5KW4.0KW5.0KW6.0KW6.5KW7.0KWOtherLevelersNoneManualHydraulicElectricBackup Camera

Monitor PanelPower TongueElectric StepAux/Roof Mount AC

# of Aux/Roof ACAux Heater# of Aux Heaters

Other Items:

Recreational Vehicle Conditions

Seats Cond3 Average1 Excellent2 Above Average4 Below Average5 PoorDash Cond3 Average1 Excellent2 Above Average4 Below Average5 PoorCarpet Cond3 Average1 Excellent2 Above Average4 Below Average5 Poor

Headliner Cond 3 Average1 Excellent2 Above Average4 Below Average5 PoorLiving Area 3 Average1 Excellent2 Above Average4 Below Average5 PoorEngine Cond3 Average1 Excellent2 Above Average4 Below Average5 Poor

Trans Cond3 Average1 Excellent2 Above Average4 Below Average5 PoorBody Cond3 Average1 Excellent2 Above Average4 Below Average5 PoorPaint Cond3 Average1 Excellent2 Above Average4 Below Average5 Poor

Glass Cond3 Average1 Excellent2 Above Average4 Below Average5 PoorFront Wear Remaining % Rear Wear Remaining %

Refurbishments:Type of RefurbDate 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 .