ESTIMATION FORM REPAIRER DETAILS COMPANY NAME COMPANY ADDRESS CONTACT PERSON NAME DESIGNATION CLAIM TYPE

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Rachel Morton
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1 ESTIMATION FORM REPAIRER DETAILS V.2.0 COMPANY NAME COMPANY ADDRESS CONTACT PERSON NAME DESIGNATION TEL : FAX : CLAIM TYPE OWN DAMAGE (OD) WINDSCREEN OD-THEFT RECOVERY OD-ACTUAL TOTAL LOSS OD-BEYOND ECONOMICAL REPAIR (BER) OD-CONTRACT REPAIR OD-KFK THEFT THIRD PARTY PROPERTY DAMAGE (TPPD) THIRD PARTY BODILY INJURY (TPBI) TICK ONE P ACCIDENT INFORMATION DAMAGE CATEGORY ACTUAL TOTAL LOSS (ATL) BEYOND ECONOMICAL REPAIR (BER) CONTRACT REPAIR REPAIRABLE DAMAGES CASH-IN-LIEU TICK ONE P ACCIDENT DATE ( d/m/y ) LOCATION OF DAMAGED VEHICLE VEHICLE TOWED TO WORKSHOP DRIVEABLE? Yes No Yes 3RD PARTY INVOLVED? Yes No No Page 1

2 ACCIDENT INFORMATION POLICE REPORT NUMBER REPORT DATE POLICE STATION STATE POLICE STATION ID NUMBER INVESTIGATION OFFICER (IO) NAME IO ID NUMBER INSURANCE INFORMATION INSURANCE COMPANY NAME POLICY NUMBER COVERAGE PERIOD START DATE ( d/m/y ) END DATE ( d/m/y ) SUM INSURED ( RM ) MARKET VALUE ( RM ) WINDSCREEN COVERAGE Yes No AMOUNT COVERED ( RM ) OWNER / DRIVER INFORMATION NAME ADDRESS POSTCODE CITY STATE COUNTRY MOBILE NUMBER OFFICE NO HOME PHONE OFFICE NO GENDER DOB ( d/m/y ) START DATE ( d/m/y ) LICENSE CLASS DRIVING LICENSE NO EXPIRY DATE ( d/m/y ) Page 2

3 Vehicle Occupancy : ACCIDENT CIRCUMSTANCES AND VEHICLE OCCUPANCY Accident Circumstances : ADDITIONAL INFORMATION Page 3

VEHICLE DATA MAKE MODEL TRIM LEVEL ENGINE SIZE GEARBOX FUEL TYPE REGISTRATION NUMBER DERIVATIVE Manual Automatic Petrol Diesel LPG Hybrid PAINT Solid COB Metallic COB Pearl COB BODY SHAPE Saloon

4 VEHICLE DATA MAKE MODEL TRIM LEVEL ENGINE SIZE GEARBOX FUEL TYPE REGISTRATION NUMBER DERIVATIVE Manual Automatic Petrol Diesel LPG Hybrid PAINT Solid COB Metallic COB Pearl COB BODY SHAPE Saloon Hatch Estate Conv. Coupe MPV LCV 4X4 VEHICLE IDENTIFICATION NUMBER ( VIN ) AUDIO UNIT ( MODEL REF. ) ODOMETER READING NO. OF DOORS FITTED OPTIONS AIRBAGS Front Knee Front (seat/door) Rear (seat/door) Anti Submarine Curtain Driver Pass. Driver Driver Pass. L/hand R/hand Driver Pass. L/hand R/hand Rear head SEAT BELT Pre tensioners Driver Pass. Depl. L/hand Depl. Depl. Centre R/hand Depl. Depl. ABS ESC Cruise Air Con. Blower S/roof Sat. Nav/GPS Alloys Xenon Reverse Sensors Tinted Alarm/Iob. STATIC TEST WARNING LAMPS ILLUMINATED COLOUR CODED Foot Brake Steering Parking Brake SRS ESC ABS Engine Mngt. Coolant Other Bump. Mould. Mirror. Handl. Pass Fail Pass Fail Pass Fail Tyre - L/hand Front Seat - L/hand Front Tyre - R/hand Front Seat - R/hand Front Seat - L/hand Rear Seat - R/hand Rear Seat - Centre Rear Tyre - L/hand Rear Tyre - R/hand Rear Tyre - R/hand inner (truck) Tyre - L/hand inner (truck) Tyre - Spare Page 4

5 Repair Specification Sheet 1 Action: N = Renew R/R = Remove and Refit S = Straighten P = Paint only B = Blend C/R = Check and report SC = Specialist charge Operation: M.E.T. = Mechanical, Electrical and Trim CP = Corrosion Protection Ref Part Description / Repair Action Action M.E.T. Panel Paint CP Others Opinion Times Totals for this sheet Page 5

6 Repair Specification Sheet 2 Action: N = Renew R/R = Remove and Refit S = Straighten P = Paint only B = Blend C/R = Check and report SC = Specialist charge Operation: M.E.T. = Mechanical, Electrical and Trim CP = Corrosion Protection Ref Part Description / Repair Action Action M.E.T. Panel Paint CP Others Opinion Times Totals for this sheet Totals Brought Forward Total Page 6

7 Repair Specification Sheet 3 Action: N = Renew R/R = Remove and Refit S = Straighten P = Paint only B = Blend C/R = Check and report SC = Specialist charge Operation: M.E.T. = Mechanical, Electrical and Trim CP = Corrosion Protection Ref Part Description / Repair Action Action M.E.T. Panel Paint CP Others Opinion Times Totals for this sheet Totals Brought Forward Total Page 7

8 Repair Specification Sheet 3 Action: N = Renew R/R = Remove and Refit S = Straighten P = Paint only B = Blend C/R = Check and report SC = Specialist charge Operation: M.E.T. = Mechanical, Electrical and Trim CP = Corrosion Protection Ref Part Description / Repair Action Action M.E.T. Panel Paint CP Others Opinion Times Totals for this sheet Totals Brought Forward Total Page 8

Fitted Extras Value Mileage 22,203. Road Tax 12 Months CC 1598

Fitted Extras Value Mileage 22,203. Road Tax 12 Months CC 1598 9,999 SCAN THE QR CODE FOR MORE VEHICLE AND FINANCE DETAILS ON THIS CAR Overview Make VAUXHALL Reg Date 2015 Model MOKKA Type Hatchback Description Fitted Extras Value 229.17 Mileage 22,203 Road Tax 12