Paul Lucht and Sons - Body Shop - Truck and Heavy Equipment Repair of All Kinds - RV's, Busses, Fiberglass Boat Repair, Trailers and MORE !

Accounts

Customer Information Form

INSURANCE COMPANY INFORMATION
Insurance Company **
Insurance Adjuster's Name **
Insurance Company's Telephone Number **
Insurance Adjusters Extension Number
Insurance Adjusters Fax Number **
Insurance Adjusters Cell Phone
Insurance Adjusters E-Mail Address **
Today's Date **	Month Day Year
Claims Order Number **
Estimator or Claims Writer **
Make of Vehicle **
Year of Vehicle **
Model Number or Name of Vehicle **
License Number **
Vehicle Number (If Applicable)
Miles on Vehicle
Serial Number of Vehicle
Owner or Business Information
Owner of Vehicle or Business Name **
Address of Owner **
Telephone Number of Owner **
Cell Phone Number
Fax Number
E-Mail Address
Damage Estimate Based On Insurance Adjusters Inspection
Description of Damage **
Material Estimates
Labor Estimates
List Materials or Body / Mechanical Parts
Do You Have Pictures Of the Damage	Yes No
Can You E-Mail Pictures of the Damage?	Yes No
Contact Information
Do You Want Us To Contact You	Yes No
How Do You Want Us To Contact You	Phone E-Mail Cell Phone Fax
Do You Want A Detailed Estimate Based On The Information That You Submitted ( Guess-timate)	Yes No
Can You Bring Your Vehicle In For a True Estimate	Yes No
When Can You Bring Your Vehicle In

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