Claim Information for your Diminished Value/Loss of Use recovery Tell us about yourself:Please fill out the following information request form so that our staff will have a complete understanding of your claim. Accuracy is important in developing a successful recovery plan.Name* First Last Email* Daytime telephone*Your State of Residence*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingYour LossMy claim is for:Diminished ValueLoss of UseDiminished Value and Loss of UseWas the accident your fault?*NOYESAbout your vehicleVehicle year*2018201720162015201420132012201120102009200820072006200520042003200220012000older than 2000Vehicle make*(Choose one)Unlisted Exotic VehicleAcuraAston MartinAudiBentleyBMWBuickCadillacChevroletChryslerDodgeFerrariFIATFordGMCHondaHyundaiInfinitiJaguarJeepKiaLamborghiniLand RoverLexusLincolnLotusMaseratiMazdaMcLarenMercedes-BenzMINIMitsubishiNissanPorscheRamRolls-RoyceScionsmartSRTSubaruTeslaToyotaVolkswagenVolvoVehicle model*Example: EX, LX, LTD, Mileage (estimated)*About the Insurance CompanyInsurance Company Name*This is the company who paid this claimClaim Number assigned to this loss*Date of Loss*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Name of Adjuster/File Handler assigned to claim*Their Telephone Number*Total Damage Amount*Please fax a copy of the final repair order to: 866-546-2849Faxed FINAL Repair Order to 866-546-2849? YES-Repair Order is Faxed! NO, I emailed it! If you prefer to scan and email this information, email to: firstname.lastname@example.orgYour Rental Car InformationIf your claim also included Loss of Vehicle Use Recovery, please continue below. If not, check the NO box below. Loss of Use* Yes! I'm filing a Loss of Use Claim No-only Diminished Value applies Number of Days my vehicle was not available for my useNumber of days from the date of loss until your vehicle was repaired and returned to youWere you provided a rental car? Yes, I had a rental car No Number of days rental was usedFax your rental receipt to 866-546-2849* Yes, I've faxed it! No, I emailed it I don't have a copy of the receipt If preferred, you may scan and email to: email@example.comLegal Disclaimer:* I agree with the statement below! I understand that any information which I receive from Ready2Appraise,Inc. does not constitute legal advice. If I am seeking legal advice, I will contact a licensed attorney in my state. CAPTCHA A word about privacy: We will NEVER share your information from this site. We respect your privacy as much as ours! Go here to view our complete privacy statement.