B & E Appraisal Service
Claim Form


Please provide as much information as possible. You will receive a confirmation email upon submitting the form.

Your E-Mail Address
Claim Number
Service Needed
Photos
Company Name
Company Tel
Adjuster Name
Date of Loss Mo   Date   Year
Type of Loss Collision
Comprehensive
Liability
none of the above
Other Type of Loss
Deductible
Insured Information
Insured Name
Insured Address
Insured Tel (Home)
Insured Tel (Work)
Insured Cell
Claimant Information
Claimant Name
Claimant Address
Claimant Tel (Work)
Claimant Tel (Home)
Claimant Cell
Vehicle Information
Vehicle Year
Vehicle Make
Vehicle Model
Vehicle Lic
Vehicle VIN
Vehicle Color
Vehicle Address
Vehicle Tel
Agreed Price Amount
Vehicle Damage
Vehicle Damage
(check all that apply)
Front
Rear
Left Side
Right Side
Roll
Under
Fire
Vandal
Summary Information
COMMENTS

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Validation