Facts of Loss

Name*
First Last
Vehicle*
Folder # (optional)
Were you driving?
If not, who?
Phone # of driver if not you.
Approximate Speed:
Number of People in vehicle:
What Seats were occupied during the accident? Please check one:
- Driver Front
- Passenger Front
- Driver Rear
- Passenger Rear
- Third Row
Was the vehicle pushed into a curb?
Did the vehicle go off road?
Were there any dash lights on prior to the accident? (i.e. - airbag, check engine, tire pressure, windshield fluid, steering, change oil, etc.)
Were there any dash lights on after to the accident? (i.e. - airbag, check engine, tire pressure, windshield fluid, steering, change oil, etc.)
Facts of Loss. Tell us what happened during the accident to better assist our Technician with the repairs:
Was anything inside the vehicle that could have caused damage to the interior? (i.e. a cup of coffee, a soda, anything heavy to damage door panels or windows, etc)
Are there any areas of damage on the vehicle NOT related to this accident?
Repair Location*
Signature*
Date*
Date Format: MM slash DD slash YYYY