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

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:

Address Line 1:

Address Line 2:

City:

State:

Zip Code:

Contact Information