Insurance Carrier *

Claim Number *

Insured Full Name *

Vehicle Owner (if different) *

Vehicle Year / Make/Model *

VIN Number *

Odometer/Current Mileage *

Date of Loss *

Is Vehicle Drivable? *

Yes

Appraiser Full Name *

Appraiser Phone Number *

Appraiser Email *

Appraiser Supervisor Full Name *

Appraiser Supervisor Email *

Appraiser Supervisor Phone Number *

Adjuster Full Name *

Adjuster Email *

Adjuster Phone Number *

Supplement Date *

Supplement Total

Is Deductible Paid? *

Yes

Deductible Owed *

Direction to Pay on File? *

Yes

Body Labor Rate ($/hr) *

Paint Labor Rate ($/hr) *

Mechanical Labor Rate ($/hr) *

Frame Labor Rate ($/hr) *

Structural Labor Rate ($/hr) *

Aluminum Repair Labor Rate ($/hr) *

Carbon Fiber Repair Labor Rate ($/hr) *

Fiberglass Repair Labor Rate ($/hr) *

Electrical / Diagnostic Labor Rate ($/hr) *

EV / Hybrid Labor Rate ($/hr) *

Claim Status Determination *

Supplement Payment Amount ? *

I acknowledge OEM repair procedures supersede estimating software guidelines.*

I acknowledge delays in supplement approval or payment may result in storage and administrative charges.*

I acknowledge that any denied or reduced line item must be accompanied by written documentation identifying the reason for deviation from OEM procedure.

I confirm that I have reviewed all attached documentation and that my determinations comply with applicable state regulations and OEM repair standards.