Claims - Plus Customer Information Entry Form for Service Vehicle owner's full name* First Last Street address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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?*YesNoI 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 35761Date 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 $250 when paying by credit card. should an additional report be needed due to prior accident damage, cost will increase by $125. A minimum charge of $50.00 may apply. If a Carfax report is needed an extra cost of $50.00 may apply.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*CAPTCHA