About Us
Services
File Number:
Policy Number:
Date of Loss:
Name of Insured:
Name of Claimant:
Address Line 1:
Address Line 2:
City:
State:
Zip Code:
Home Phone:
Business Phone:
Everett Smith & Associates, Inc.
On-Line Damage Appraisal Assignment Form
Vehicle Year:
Vehicle Make:
Vehicle Model:
Vehicle Color:
Vehicle License:
VIN:
Insurance Type:
Deductible:
Point of Impact / Loss Description:
Special Instructions:
Is the Vehicle Drivable?
Name of Shop 1:
Estimate of Shop 1:
Vehicle Location:
Name of Shop 2:
Estimate of Shop 2:
Appraisal Instructions
Instructions:
Other Instructions:
Photos:
Photo Format:
Total Loss Instructions
Complete A.C.V. worksheet at
% of base book value. (0-100%)
Or, Select from List:
Salvage Instructions
Move to Pool?
Call Back Instructions
Call Back To:
Other Contact Name:
Other Contact Number:
Call if:
Claim Information
Company Information
Company Name:
Adjuster’s Name:
Adjuster’s Phone:
Adjuster’s Fax:
Adjuster’s E-Mail:
Contact Information