Appraisal Assignment Submission    

Important!
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Insurance Company Name
Adjusting Firm
Adjuster Name:

Adjuster File Number
Adjuster Telephone
Adjuster City/Province:
Adjuster E-mail
Claim & Policy Number:
Information about Vehicle Owner
Insured's Name:

Vehicle's Owner Name
Address:
City / Province:
Home Telephone:
Work Telephone:
Information about Vehicle
Date of Loss:
Endorsement 43R
Deductible Amount:
Type of Loss
Vehicle owner pays GST:
Year / Make / Model :
VIN (Last 8):
Plate Number:
Damage Description:
Information on Body Shop
Shop Name:
Telephone:
Notes to Appraiser: