Claims - Plus Customer Information Entry Form for Service

Vehicle owner's full name*
First Last
Street address*
Street Address Address Line 2 City State ZIP Code
Contact phone number*
Email*
Make of vehicle*
Model*
Color*
Miles at time of damage*
Vehicle Identification number*
Has your vehicle ever been damaged and repaired before?*
- Yes
- No
- I don't know
* If yes, please mail or scan and send by email the repair estimate from the older accident to Loss@claims-plus.com or mail to Claims-Plus, Inc. P.O. Box 519, New Market, AL 35761
Date newer damage occurred*
Date Format: MM slash DD slash YYYY
Repair Shop*
Repair estimate or cost*
Repair Shop phone number*
Cost of 1 report is $225 if paying by check; $250 if paying by credit card. should an additional report be needed due to prior accident damage, cost will increase by $125.
Name as it appears on Credit Card*
Billing Zip Code*
Full 16 digit credit card number*
Thank you for allowing us to serve you!
Expire date*
3 digit CSV number on back of card*
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