Transcription of Liberty Mutual Agency Market Basic Claim …
1 Liberty Mutual Agency Market Basic Claim Information Form Phone: (800) 621- CCC Information Services Inc. 8070. Fax: (800) 621-7070. ADMINISTRATIVE. LMAM Secondary Company Code See company list on back of form (Enter the company code for the company name you wish to display in the heading of the CCC Valuescope Market Report). Office ID Number: See ID list on back of form, enter 5 digit ID for proper state/product Claim Number: Adjr. Last Name: 1st Name: Insured's Name: Owner's Name: Owner's Phone #: Owner's ZIP Code: State: Exch#/Policy Number: Adjuster ID#: Claim Class: PA Appraiser ID #: Email address: Fax Back to: Type of Loss: T (Theft) C (Other). VIN. State: Loss Date: Year Make Model Body Style: 2DR 4DR Lift/Hatchback Convertible Wagon Pickup Van Utility Ton Ton Shortbed Longbed Cab & Chassis Fleetside Fenderside Engine Detail Size: Cylinders: 3 4 5 6 8 12 10 Turbo Diesel Transmission: AT S6 S5 S4 S3 OD 4W PO TX. Mileage ( UNK if unknown). VEHICLE OPTIONS. Power Options Radio Options Wheel Options Truck / Van / Utv / Other PS Power Steering AM AM AW Aluminum Wheels/ SB Step Bumper PB Power Brakes FM FM Alloy Wheels SW Sliding Rear Window PW Power Windows ST Stereo LC Locking Whl.
2 Covers XT Auxiliary Fuel Tank PL Power Locks CA Cassette SA Spoked Alum. Wheels D2 Deluxe 2-Tone Paint SP Pwr. Drive Seat SE Seek/Scan SY Styled Steel Wheels BD Running Boards/. PC Pwr. Pass. Seat 8T 8 Track WW Wire Wheels Side Steps PA Power Antenna CB CB Radio WC Wire Wheel Covers BL Bed Liner PM Power Mirrors EQ Equalizer RW Rally Wheels AR Bed Rails PT Power Trunk/Tailgate BM Bose Music System DC Deluxe Whl. Covers TP Towing Package IS Infinity Sound TN Tonneau Cover D cor/Convenience JB JBL Stereo Other Options RB Roll Bar AC Air Conditioning CD Compact Disc Player WG Wood grain TB Permanent Tool Box DA Dual AC SK CD BN Body Side Molding GG Grill Guards Changer/Stacker RD Rear Defogger TQ Steering Wheel BS Bucket Seats WD Dual Rear Wheels TW Tilt Wheel Touch Controls HB Hiback Bucket Seats A2 2 Whl. Antilock Brakes CC Cruise Control RL Reclining Seats CP Fiberglass Top CS Cloth Seats Roof Options BP Split Bench Seats 7P 7 Pass. Seating LS Leather Seats VR Vinyl Roof IW Intermittent Wipers 8P 8 Pass.
3 Seating SH Heated Seats (2) ES Electric Steel WP Rear Window Wiper 2P 12 Pass. Seating DB 4 Wheel Disc Brakes EG Electric Glass TG Tinted Glass 5P 15 Pass. Seating TL Telescopic Wheel MS Manual Steel MP Metallic Paint SS Swivel / Capt. Chairs AL Auto Load Level MG Manual Glass 2T 2 Tone Paint B4 4 Capt. Chairs 3S 3rd Seat (Wagons Only) FR Flip Roof DT Deep Ting Glass B6 6 Capt. Chairs DM Dual Mirrors SR Sun Roof AG Air Bag 3D 3rdTruck Door FL Fog Lights SD Dual Power Roofs RG Pass. Air Bag 4D 4th Door Truck/Van KE Keyless Entry TT T-Tops/Panel XG Front Side Air Bag PD Pwr. Sliding Door TD Theft Deterrent GT Glass T-Top/Panel ZG Rear Side Air Bag EC Entertainment Center SL Rear Spoiler CT Soft Top AB Antilock Brakes HT Hard Top NV Navigation System VP Pwr. Conv. Roof RR Roof Rack RM Detachable Roof REFURBISHMENTS. Transmission Purchase price Mileage Engine Purchase price Mileage Tires Purchase price # Of 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 Purchase price Date Restored Restoration Amount Package / Special Features / Additional options (XXXX=call back): Email response to: CONDITION RATING.
4 Rate each of the following: o = Fair, 1 = Average Private, 2 = Dealer Retail, 3 = Above Average COMMENTS. MC Mechanical 0 1 2 3. BG Body/Glass 0 1 2 3. P Paint 0 1 2 3. I Interior 0 1 2 3. T Tires 0 1 2 3. ADJUSTMENTS. Pre Tax Adjustments 1: Add Deduct Pre Tax Adjustment 2: Add Deduct Sales Tax % Leave blank if using AutoTax Deductible: Post Tax Adjustment 1: Add Deduct Post Tax Adjustment2: Add Deduct
