CCC Valuescope Basic Claim information Form

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Owner's PhoneCCC Valuescope Basic Claim information FormEmailFaxReport RetrievalOther (Specify)MethodCCC Phone 1-800-621-8070CCC Fax 1-800-621-7070CCC Email ID NumberClaim NumberAdjr Name (First & Last)Appr Name (First & Last)Insured NameAdjr Contact#Loss ZIP CodeLoss StateCollisionTheftCollisionOtherLoss TypeCoverage codeComprehensiveLiabilityYesNoLeased VehicleYesNo3rd Party ClaimDate of LossExch#Policy # Claim ClassAdjuster ID#PA Appr ID#VINYearMakeModel2DR4DRHatchbackConver tibleVanBody StyleWagonPickupUtilityTonShort BedCab & ChassisFleetsideFenderside1 Ton3/4 TonLong Bed1012TurboDiesel34568Engine SizeCylindersMileage ( UNK If unknown)

CCC Valuescope Basic Claim information Form (Continued) Office ID Number REFURBISHMENTS Transmission Engine Tires Paint Basic Standard Custom Date Painted Purchase Price Interior Purchase Price Date Leather Vinyl Cloth Camper Shell Purchase Price Date Carpet Kit Purchase Price Date Special Wheels Purchase Price Date Other Description …