*Indicates Required Field
CRV Office ID Number*
Report Retrieval Method* / Email / Fax / Other
Claim Representative Last Name* / Claim Representative First Name*
Claim Representative Email* / Claim Representative Contact Number*
Date of loss (mm/dd/yyyy) * / Claim Number*
Policy Number / Type of Loss* / Collision / Theft / Other
Insured Name* / Insured Phone Number
Claimant Name / Claimant Phone Number
LossState* / Loss ZIP Code*
VIN*
Year* / Make* / Model*
Odometer / External Color
Overall Condition Ratings* / (1) Below Average / (2) Average / (3) Exceptional
Cab Type Open Cab Enclosed Cab / Articulating Yes No
Drive 2 Wheel Drive 4 Wheel Drive
Engine / Gas / Diesel / Electric / Propane
Make / Model / Horsepower / Number of Gears
Transmission / Power Shift / Straight Shift / Manual Shift / Hydrostatic
Auxiliary Trans Yes No / Use Type Private Commercial
Rebuilt Engine Yes No / Miles on Rebuilt / Cost of Rebuilt $
Rebuilt Transmission Yes No / Miles on Rebuilt / Cost of Rebuilt $
Equipment Options
Power Steering
Cruise Control
Tilt Wheel
Air Conditioning / Heater
Insulation Package
Roll Over Protection System
Suspension Seat / PTO
Blade Size inches
Wet Kit / Windows Glass Other
Outriggers
4 Wheel Drive
Skid Steer
Auxiliary Hydraulics / Hand Controls / Foot Controls / Back Up Alarm
Front Loader Size inches yards
Other Attachments (Include additional information in the Notes Section)
Manufacturer / Model / Year
Backhoe
Front Loader Size inches yards / Rear Bucket Size inches
Grapples / Forks / Thumbs
Auxiliary Hydraulics / Extend-a-hoe / Quick Coupler
Excavator
Front Loader Size inches yards / Undercarriage % remaining
Extended Boom / Thumbs
Crane
Capacity Tons / Maximum Extension ft. / Regular Terrain
Rough Terrain / Trailer Mounted / Self-Propelled
Forklifts
Total Capacity lbs. / 1st Stage ft. / 2nd State ft. / LiftRange ft.
Ram Lift / Chain Lift / Towable / Street Legal
Crawler Dozer
6-way Blade / Front Blade Size yards / Undercarriage % remaining / Rear Ripper Number of Teeth
Combine
Corn / Wheat / Rice / Cotton
Chopper / Header rows
Tires/Tracks
Pneumatic Tires / Solid Tires / Steel Tracks / Rubber Tracks / Tracks over Tires
Heavy Equipment Basic Claim Information Form (Continued)
Office ID Number / Claim Number
Farm Tractors
Dual Rear Wheels / Rear Attachments / PTO / 3 Point Hitch
Front Loader Size inches yards / Other Attachments(Include additional information in the Notes Section)
Manufacturer / Model / Year
ADDITIONAL EQUIPMENT (include price if applicable):
ADJUSTMENTS
Pre Tax Adjustment 1 / Add / Deduct
Pre Tax Adjustment 2 / Add / Deduct
Sales Tax % / Deductible
Post Tax Adjustment 1 / Add / Deduct
Post Tax Adjustment 2 / Add / Deduct
Notes
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