Manders Damage Appraisal Request Form
Please complete ALL fields
Policy Number
Claim Number
Date of Loss
 
Endorsement 43R ?  Yes           No
Deductible (please check one)  None        $250        $500         Other
If "Other", please enter deductible amount
Insured pays GST ?  Yes          No
Type of Loss  Collision      Liability      Comprehensive
 
Insurer
Adjuster
Phone Number
Fax Number
 
Owner Name
Home Phone
Business Phone
Email Address
Residence or Business Address
Vehicle, Year, Make, Model, Colour
Licence Number
VIN
Area of Damage
 
Shop Name
Phone
Address
Major Intersection
Comments