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)

Decor/Convenience B4 Captain Chairs (4) VR Vinyl Roof BN Body Side Moldings AC Air Conditioning B6 Captain Chairs (6) RF Cabriolet Roof DM Dual Mirrors ... WT Wood interior Trim CB CB Radio PJ Parking Sensors SS Swivel Seats El Electronic instrumentation 8T 8 Track Tape Player PX Parking Sensors W/Equip SW Rear Sliding Window

  Swivel, Chair