Customer Information Service Request Form

Date: 

Name: 

Address: 

City: 

State:   Zip Code:

Home Phone: 

   Work Phone:

Cell Phone: 

      Alt. Phone:

e-mail: 

Best Time to contact: 

 

Vehicle Profile

Vehicle Year: 

  Make:

 Model: 

    VIN:

Vehicle Color: 

       License Plate:    

Insurance Company: 

  

Claim #:

Claimant: 

     Insured:      Cash Pay:                 Deductible:

Rental Needed: 

   

Damage Area: 

  

Date of Loss: 

  

 Number of seatbelts in use at the time of the accident:

How is the Vehicle Handling?

Drivable:

Non-Drivable: 

Location of Non-Drivable Vehicle: 

Location Phone #:

  Keys with Vehicle:

Tow Company:

  Charges:

   

Notes / Comments:

How did you hear about

 Bangor Body Works?