Basic Claim Information Form
*=Required Field
* Travelers Secondary
AE
T101
T801
T901
Company Code; Select One
Travelers
St. Paul Fire and Marine
Constitution State Services LLC
Northland Insurance Company
*Claim Number
*Claim Adjuster Name (First & Last)
Claim Adjuster Contact#
Owner’s Name
*Loss ZIP Code
*Loss Type
Other
Theft
3rd Party Claim
Yes
No
*Date of Loss
PA Appr ID#
*VIN
*CCC
ValueScope Office ID; Select State where vehicle
typically garaged. Use “Universal” if State not listed.
Universal= 19930
KS=19934
NV=19938
RI=19942
CA=19931
KY=19935
NY=19939
WA=19943
CT=19932
NH=19936
OR=19940
WV=19944
*Claim Adjuster ID# (if applicable)
Appraiser Name (First & Last)
*Insured’s Name
Owner’s Phone
Loss State
Coverage code Collision
Comprehensive
Leased Vehicle
Yes
No
Exch.# Policy #
Claim Class
Liability
DE=19933
NJ=19937
PA=19941
CRV=19945
Other
*Year
*Make
*Model
Package 1:
Package 2:
Body Style
2DR
4DR
Hatchback
Convertible
Wagon
Pickup
Van
Utility
½ Ton
¾ Ton
1 Ton
Short Bed
Long Bed
Cab & Chassis
Fleetside
Fenderside
Engine Size
Cylinders
3
4
5
6
8
10
12
Turbo
Diesel
*Mileage (“UNK” if unknown)
*Transmission
Automatic
Overdrive
S6
S5
S4
S3
4W
Power Options
Seating
Roof
Exterior/Paint/Glass
PS Power Steering
CS Cloth Seats
EG Electric Glass Roof
DM Dual Mirrors
PB Power Brakes
BS Bucket Seats
ES Electric Steel Roof
HM Heated Mirrors
PW Power Windows
RL Reclining/Lounge Seats
OR Skyview Roof
BN Body Side Moldings
PL Power Locks
LS Leather Seats
SD Dual Power Sunroof
TG Tinted Glass
PM Power Mirrors
SH Heated Seats
MS Manual Steel Roof
AF Aftermarket Film Tint
SP Power Driver Seat
RH Rear Heated Seats
MG Manual Glass Roof
DT Privacy Glass
PC Power Passenger Seat
VB Ventilated Seats
FR Flip Roof
WP Rear Window Wiper
PT Power Trunk/Gate Release
3S 3rd Row Seat
TT T-Top/Panel
FL Fog Lamps
PP Power Adjustable Pedals
3P Power Third Seat
VP Power Convertible Roof
RR Luggage/Roof Rack
PD Power Sliding Door
R3 Retractable Seats
RM Detachable Roof
SL Rear Spoiler
DP Dual Power Sliding Doors
2P 12 Passenger Seating
VR Vinyl Covered Roof
HV Headlamp Washers
Décor/Convenience
5P 15 Passenger Seating
HT Hard Top
MX Signal Integrated Mirrors
AC Air Conditioning
B2 Captain Chairs (2)
Safety/Brakes
WG Wood grain
CL Climate Control
B4 Captain Chairs (4)
AG Driver’s Side Air Bag
IP Clear coat Paint
DA Dual Air Conditioning
B6 Captain Chairs (6)
RG Passenger Air Bag
MP Metallic Paint
TW Tilt Wheel
Radio
XG Front Side Impact Air Bags
2T Two Tone Paint
CC Cruise Control
AM AM Radio
ZG Rear Side Impact Air Bags
HP Three Stage Paint
IW Intermittent Wipers
FM FM Radio
DG Head/Curtain Air Bags
Other
CN Console/Storage
ST Stereo
DB 4-Wheel Disc Brakes
SB Rear Step Bumper
CO Overhead Console
SE Search/Seek
AB Anti-Lock Brakes (4)
TH Trailer Hitch
MM Memory Package
CD CD Player
A2 Anti-Lock Brakes (2)
TP Trailering Package
NV Navigation System
CA Cassette
TX Traction Control
SW Rear Sliding Window
EC Entertainment Center
TQ Steering Wheel Touch Controls
T1 Stability Control
PG Power Rear Window
DU Dual Entertainment Center
M3 Auxiliary Audio Connection
PO Positraction
BD Running Board/Side Steps
TL Telescopic Wheel
UR Premium Radio
C2 Communications System
UP Power Retractable
MC Message Center
SK CD Changer/Stacker
PJ Parking Sensors
Running Boards
GD Home Link
XM Satellite Radio
PX Backup Camera W/ Sensors
BL Bed liner
RD Rear Defogger
EQ Equalizer
TD Alarm
BY Bed liner (Spray On)
RJ Remote Starter
Wheels
HF Hands Free Device
TN Soft Tonneau Cover
WT Wood Interior Trim
SY Styled Steel Wheels
XE Xenon Headlamps
TZ Hard Tonneau Cover
KE Keyless Entry
FC Full Wheel Covers
HU Heads Up Display
CP Deluxe Truck Cap
SZ Rear Power Sunshade
CY Clad Wheels
IC Intelligent Cruise
AR Bed Rails
AW Aluminum/Alloy Wheels
DV Blind Spot Detection
GG Grill Guard
CJ Chrome Wheels
LN Lane Departure Warning
TB Tool Box (Permanent)
W2 20” or Larger Wheels
VZ Night Vision
WD Dual Rear Wheels
WW Wire Wheels
RB Roll Bar
XT Auxiliary Fuel Tank
WC Wire Wheel Covers
EM California Emissions
KW Locking Wheels
SG Stone Guard
WI Winch
CCC ONE™ Valuation
BCIF1FAALL TC (Travelers May 2015)
Basic Claim Information Form
*=Required Field
REFURBISHMENTS
Transmission
Purchase Price
Mileage
Engine Purchase Price
Tires
Purchase Price
# of Tires
Paint
Basic
Standard
Custom
Date Painted
Purchase Price
Interior
Purchase Price
Date
Leather
Vinyl
Camper Shell
Purchase Price
Date
Carpet Kit
Purchase Price
Special Wheels
Purchase Price
Date
Other
Description
Purchase Price
Restored
Restored Amount
Special Features/Additional Options (XXXX=CALL BACK)
CONDITION RATING: 0=Below Average, 1=Private Owner, 2=Dealer Ready, 3=Excellent
COMMENTS
*Seats
0
1
2
3
*Carpet
0
1
2
3
*Dashboard
0
1
2
3
*Headliner
0
1
2
3
*Sheet Metal
0
1
2
3
*Trim
0
1
2
3
*Paint
0
1
2
3
*Glass
0
1
2
3
*Engine
0
1
2
3
*Transmission
0
1
2
3
*Front Tires
0
1
2
3
*Rear Tires
0
1
2
3
ADJUSTMENTS
Pre Tax Adjustment 1
Pre Tax Adjustment 2
Sales Tax %
Leave blank if using AutoTax
Post Tax Adjustment 1
Post Tax Adjustment 2
PROCESSING INSTRUCTIONS
Expand comparable search (if needed)
Replacement Policy
Report Retrieval
Email
Method
CCC Phone: 1-800-621-8070
CCC ONE™ Valuation
Add
Add
Deductible
Add
Add
Mileage
Cloth
Date
Date
Deduct
Deduct
Deduct
Deduct
Dealership where purchased (if known)
Fax
Other (Specify)
CCC Fax: 1-800-621-7070 CCC Email: [email protected]
BCIF2FAALL TC (Travelers May 2015)