Pickup Request

User Information:

Your Name:

Your Email Address:

Company Information:

Insurance Company:

Allianz Global Risk

Dufferin Mutual

HB Group

Wawanesa Mutual Insurance Co.:

Barrie	Hamilton	London	Ottawa	Peterborough
Toronto	Waterloo

Other:  

Adjuster:

Phone #:     Email Address:

Appraiser:  

Claim # / Policy #:  

Name of Insured:  

Date of Loss:   (MM/DD/YYYY)

Brand:  Salvage   Irreparable   None   Unknown


Vehicle Information:

Year:     Make:     Model:

VIN #:      License Plate #:

Mileage:

Salvage Located at:
Name: Address: City: Phone:

Payout Tow Bill(s):   Subtotal Before Taxes

Start Storage Date:   (MM/DD/YYYY)

Storage Cost Per Day:  

Miscellaneous Expenses:  

Settlement ACV Before Tax:  

Special Instructions: