DVclaim

Diminished Value Claim Information Request Form

Was this accident your fault? (PLEASE NOTE: If the accident was your fault, you have no ability to recover diminished value.

Yes

Date

Vehicle Owner Name

Vehicle Owner Phone Number

Vehicle Owner Email

Vehicle Owner Address

Insurance Company

Claim Representative

Claim Rep. Contact Number

Claim Rep. Email Address

Claim / Policy Number

State Vehicle Owned In

Attach Copy of Title / Registration

Attach Original Bill of Sale for Vehicle

Vehicle Year

Vehicle Make

Vehicle Model

VIN

Date of Loss

Mileage (at date of loss)

Final costs of repairs, including all supplements. (Insurance Company Paid Amount)

Structural Damage Reported?

Yes

Does this vehicle have any previous accidents?

Yes

Insurance Damage Estimate

At Fault Insurance Company Name

At Fault Insurance Company Claim Number

At Fault Insurance Company Claim Representative

At Fault Insurance Company Claim Representative Phone Number

At Fault Insurance Company Claim Representative Email