Customer information form 3 20 17

Customer Contract and Information form for Purchasing Individual Auto Diminished Value Report

First Name

Last Name

Phone Number

Street

City

State

Zip Code

Email

Vehicle Information

Make

Model

Trim Package

Miles at time of accident

Current Miles

Vehicle Idenfication Number

Color

Condition before Accident

Fair Good Excellent

Has this vehicle been damaged and repaired prior to this damage?

YES NO

Damage Date

Where was the vehicle when the damage occured?

Breifly describe the accident or damage

Repair Shop

Shop Phone#

Estimated Repair Cost

Payment Information

Choose Payment Method Below: Cost of single report is $225.00

I choose to pay by the following method:

Visa Master Card

Card Number

Name as it appears on card

Expire Date

Pin Code

By completing this form and returning to Claims-Plus, Inc. I agree to have charges placed upon my credit card in the amount listed above, when credit card box has been marked. I also certify that all the information given above is true to the best of my knowledge. I agree that Claims-Plus, Inc will not be responsible or liable for any amounts collected or not collected from the responsible party. The report I am purchasing is derived from research completed from information from industry sources commonly found at the time of research. The amount of lost value is the opinion of the researcher based upon different sources of information at that time. Claims-Plus will not be responsible or liable for any wrongful information received from customer. This report is issued without bias to either party and is the sole opinion of Claims-Plus, Inc.