PICKUP REQUESTED BY:

date of loss:

COMPANY NAME

ADJUSTER NAME

ADJUSTER PHONE #

CLAIM  #

VEHICLE OR ITEM TO BE PICKED UP:

COLOR

VIN #

ACV  (Required)

LOCATION OF VEHICLE OR ITEM

ADDRESS

CITY AND STATE

ZIP CODE

LOCATION PHONE #

DATE AVAILABLE TO PICK-UP

INSURED OR CUSTOMERS NAME

OWNERS NAME

CONTACT PERSON

IS VEHICLE DRIVEABLE?

IS VEHICLE TOWABLE?

WHERE ARE KEYS LOCATED?

SETTLED ?

CHARGES TO BE PAID?

SPECIAL INSTRUCTIONS