CRV Office ID#:

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:

Body Type:
Conversion VanCamper Van (Class B)Mini Motor (Class C)Full Size Motor Home (Class A)5th Wheel TrailerTravel TrailerSlide On CamperPop-Up Tent TrailerPark
Length:
______
Doors:
______/ Chassis Year: ______
Chassis Manufacturer:
______
Chassis Model:
______
# of Axles:
______/ Transmission:
AutomaticManual
Odometer:
Engine Manufacturer: ______
Engine Model: ______
Engine Size: ______/ Leveling System:
YesNo
Suspension:
Spring
Air Ride
Mor-Ryde
Other
# of Slideouts:
______
PowerManual
Length of Slideouts:
1st______ft.
2nd______ft.
3rd______ft. / # of Awnings: __
Awning Length: ____ ft.
Length of Awnings:
1st______ft.
2nd______ft.
3rd______ft.
Electric Steps:
SingleDouble
Triple / Electrical:
110 Volt
12 Volt
AC/DC Converter
Inverter
______Watts
Monitor Panel
Generator
______Watts
______# of House Batteries / Rebuilt Engine: Yes No
Miles on Rebuilt______
Cost of Rebuilt $______
Rebuilt Transmission: Yes No
Miles on Rebuilt______
Cost of Rebuilt $______

Power Options

Power Steering
Power Brakes
Power Windows
Power Locks
Power Driver Seat
Power Passenger Seat
Power Antenna
Power Mirrors

Roof Options

Standard Roof
Raised Roof
Luggage/Roof Rack
Skylight Roof
Air Vent
Flip Roof

Wheels

Aluminum/Alloy Wheels
Spoked Aluminum Wheels
Syled Steel Wheels
Wire Wheels
Chrome Wheels
Rally Wheels
Aluminum Wire Wheels
Wire Wheel Covers
Custom Wheels /

Convenience

Cruise Control
Tilt Wheel
Air Conditioning
Auxiliary AC
Auxiliary Heater
Swamp Cooler
Furnace
Gas Electric
Ducted: Yes No
Auxiliary Fuel Tank
Keyless Entry
Theft Deterrent
Infinity Sound
Intermittent Wipers
Fog Lamps
Cellular Phone

Electronics

Television
Size ______inches
VCR
Game System
Electronic Hookups
AM
FM
ST
CA
Seek/Scan
CD
CB Radio
Equalizer
CD Changer Stacker
Dual Stereo
Satellite Dish
In Motion Manual
DVD /

Seat/Interior

Cloth Seats
Leather Seats
Swivel/Captains Chairs
Split Bench Seats
Bucket Seats
Reclining Lounge Seats
Fold-out Sofa Bed
Power: Yes No
Wood Trim
Full Carpeting
Insulated Walls w/ Paneling
Upholstered Door Panels
Interior Lighting
Lighted Drink Tray
Console/Storage
Overhead Console

Power Yes NoKitchen/Bath

Stove/Oven
Gas Electric
Microwave
Refrigerator
Gas Electric
Side by Side
Side by Side w/ Icemaker
Water Purifier
Garbage Disposal
Ice Box
Sink
Full Bath
Half Bath

Safety

Air Bag
Passenger Air Bag
Front Side Air Bag
4 Wheel Disc Brakes
Rearview Monitor /

Other

Body Side Moldings
Running Boards/Side Step
Trailer Hitch
Trailering Package
Pinstriping
Two Tone Paint
Metallic Paint
Custom Paint
Custom Windows
Draperies/Mini Blinds
Center Mount Game Table
Tire Rack/Carrier
Solar Panel
# of Solar Panels ______
Driver’s Side Door
Spare Tire
Propane Tank
Water Heater
Water Storage
Washer/Dryer
Central Vacuum

Levelers

Manual Stab Jacks
Electric Screw
Hydraulic Ram
Computer Controlled

Tongue Jack

Manual Electric

Holding Jack

Grey Water
Waste Water
Fresh Water
#LPG______
#Fuel______
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: