CCC Valuescope Basic Claim information Form

1 Owner's PhoneCCC Valuescope Basic Claim information FormEmailFaxReport RetrievalOther (Specify)MethodCCC Phone 1-800-621-8070 CCC Fax 1-800-621-7070 CCC 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#VINYearMakeModel2DR4 DRHatchbackConvertibleVanBody StyleWagonPickupUtilityTonShort BedCab & ChassisFleetsideFenderside1 Ton3/4 TonLong Bed1012 TurboDiesel34568 Engine SizeCylindersMileage ( UNK If unknown)

2 TransmissionAutomaticS6S5S4S3OD4 WPORoofExterior/Paint/GlassPower OptionsSeatingCS Cloth SeatsEG Electric Glass RoofPS Power SteeringRR Luggage/Roof RackPB Power BrakesLS Leather SeatsES Electric Steel RoofWG WoodgrainPW Power WindowsRL Reclining/ Lounge SeatsOR Skyview RoofWP Rear Window WiperPL Power LocksBS Bucket SeatsSD Dual Power Roofs2T Two Tone PaintSP Power Driver SeatMS Manual Steel RoofD2 Deluxe 2 Tone PaintSH Heated Seats (2)RH Rear Heated SeatsMG Manual Glass RoofPC Power Passenger SeatHP Three Stage PaintPA Power Antenna3S Third Row SeatIP Clearcoat PaintFR Flip RoofTT T-Top/PanelPM Power Mirrors3P Power Third SeatMP Metallic PaintGT Glass T-Top/PanelR3 Retractable SeatsPT Power Trunk TailgateSL Rear SpoilerMV Manual Convertible RoofPP Power Adjustable Petals2P 12 Passenger SeatingFL Fog LampsVP Power Convertible RoofTG Tinted GlassPD Power Sliding Door5P 15 Passenger SeatingRM Detachable RoofDP Dual Power Sliding DoorsB2 Captain Chairs (2)DT Privacy GlassDecor/ConvenienceB4 Captain Chairs (4)

3 VR Vinyl RoofBN Body Side MoldingsRF Cabriolet RoofDM Dual MirrorsAC Air ConditioningB6 Captain Chairs (6)RadioLR Landau RoofHM Heated MirrorsDA Dual Air ConditioningCL Climate ControlAM AM RadioLP Padded Landau RoofHV Headlamp WashersFM FM RadioRD Rear DefoggerPV Padded Vinyl RoofMX Signal Integrated MirrorsST StereoOtherIW Intermittent WipersCT Soft TopTW Tilt WheelCA CassetteHT Hard TopBD Running Board/Side StepsSE Search/SeekUP Power RetractableTL Telescopic WheelSafety/BrakesCC Cruise ControlCD Compact Disc PlayerAG Air BagRunning BoardsKE Keyless EntrySK CD Changer/StackerRG Passenger Air BagXE Xenon HeadlampsUR Premium RadioAR Bed RailsCN Console/StorageXG Front Side impact Air BagsCO Overhead ConsoleXM Satellite

4 RadioBL BedlinerZG Rear Side impact Air BagsEC Entertainment CenterTQ Steering Wheel TouchDG Head/Roof Air BagsBY Bedliner (Spray On)ControlsTD Theft Deterrent/AlarmNV Navigation SystemCP Fiberglass CapGG Grill GuardC2 Communications SystemM3 Auxiliary Audio ConnectionVZ Night VisionHU Heads Up DisplayEQ EqualizerIC Intelligent CruiseSB Rear Step BumperWT Wood interior TrimCB CB RadioSS swivel SeatsPJ Parking SensorsEl Electronic instrumentation8T 8 Track Tape PlayerPX Parking Sensors W/EquipSW Rear Sliding WindowWheelsPG Power Rear WindowIB On Board ComputerAB Anti-Lock Brakes (4)MC Message CenterAW Aluminum /Alloy WheelsA2 Anti-Lock Brakes (2)TB Tool Box (Permanent)

5 TN Tonneau Cover - SoftCJ Chrome WheelsDB 4 Wheel Disc BrakesMM Memory PackageTZ Tonneau Cover - HardRJ Remote StartRB Rollover ProtectionW2 20" or Larger WheelsDC Deluxe Wheel CoversTX Traction ControlTP Trailering PackageFC Full Wheel CoversWD Dual Rear WheelsT1 Stability ControlAL Auto LevelSA Spoke Aluminum WheelsXT Auxiliary Fuel Tank3D 3rd Truck DoorSY Styled Steel WheelsWW Wire Wheels4D 4th Door Truck/VanWC Wire Wheel CoversBC Bumper CushionsRW Rally WheelsBG Bumper GuardsEM California EmissionsKW Locking WheelsSG Stone GuardLC Locking Wheel CoversWI Winch1 Owner's Name1 Valuescope Basic Claim information Form(Continued)Office ID NumberREFURBISHMENTSE ngineTransmissionTiresStandardCustomDate PaintedPurchase PricePaintBasicDateLeatherClothVinylInte riorPurchase PriceDatePurchase PriceDateCarpet KitPurchase PriceCamper ShellDatePurchase PriceSpecial WheelsPurchase PriceDateOtherDescriptionRestoredRestore d AmountPackage/Special Features/Additional Options (XXXX=CALL BACK)

6 CONDITION RATINGCOMMENTS022301230123012301230123 Paint01 EngineFront TiresADJUSTMENTSAddDeductPre Tax Adjustment 2 DeductibleLeave blank if using AutoTaxSales TaxAddDeductPost Tax Adjustment 1 AddDeductPost Tax Adjustment 22 Claim Number13 TransmissionRear TiresPre Tax Adjustment 1 AddDeductPurchase PriceMileageRate each of the following 0=Below Average, 1=Normal, 2=Above Average, 3=ExceptionalPurchase PricePurchase PriceMileage# of