Autosource Boat Marine PDA s1

Dump / Grain / Tanker / High Cube / Reefer / Flat / Truck (PDA) Call in: 800-351-3133, menu option 3

Audatex Request # Audatex ID # (Required)

Total Loss Point of Impact: Claim Rep Name Claim Rep Phone # Loss Date Gross Estimate Amount $: Claim # Policy # Owner Name (1st) Owner Phone # Loss Type

Market Area (City/Zip/Postal Code) Inspection (City & State) Insured (2nd) Owner Phone # Claimant 10th digit-model year J=88 K=89 L=90 M=91 N=92 P=93 R=94 S=95 T=96 V=97 W=98 X=99 Y=2000 1=01 2=02 3=03 4=04 5=05 6=06 7=07 8=08 9=09 A=10 Ext Color: VIN:

Year Make Model Body Style Conventional CabType Standard Cab Drive Type COE Forward Cab Ext. Cab Crew Cab 2wd 4wd Day Cab Sleeper Cab Trim Body Type Dump Truck Grain Truck Mileage Engine Make/Model Horsepower Transmission Tanker High Cube/Reefer Auto Manual Flatbed Autoshift Transmission Make # of Gears GVW Wheel Base Suspension Type # of Rear Axles Spring Air Hendrickson Other # of Driven Axles Rear Axle Rating Front Axle Rating Drop Axle(s) Dual Rear Wheels Yes EQUIPMENT CAB EQUIPMENT Spreader Model: TANKER BODY HIGH CUBE/REEFER FLAT BED Power Steering Spreader Material Body Year: Body Year: Body Year: Power Windows Painted Steel Body Manufacture: Body Manufacture: Body Manufacture: Tank Material Body Length: Body Length: Power Locks Stainless Steel Painted Steel Body Material Body Material Cruise Control Stainless Inner Liner Stainless Steel Aluminum FRP Aluminum Steel Tilt/Telescoping Wheel Spreader Length (ft.): Spreader Capacity (yds.): Aluminum Steel Deck Material Air Conditioning Spreader Floor Type Deck Material Wood Aluminum Radio Type Lined Tank Chain Belt Tank Cap: Wood Aluminum Steel AM/FM Stereo # of Blades in Spreader Gallons: Rear Door Type Side Material AM/FM Cass 1 2 Barrels: Roll-up Swing Wood Aluminum AM/FM CD Snow Plow Oval/Round Tank Open Steel CB Radio Mount/Hydraulics Oval Round Additional Side Doors Hydraulic Lift Gate Jake Brake Mount/Hyd/Blade # of Compartments: Hydraulic Lift Gate Dumping Hoist Air Ride Seats Blade Type Baffles Rail Gate PTO Driver Passenger Straight Blade V-Blade Int./Ext. Plumbing Tuk-A-Way Gate # of Fuel Tanks: DUMP TRUCK Blade Length (ft.): Internal External Ramp Type: Total Fuel Cap # gal: Body Year: Side Wing Plow Fresh Air Vent E-Track # of ft: Crane Equipment Body Manufacture: Wing Plow Length (ft.): # of Certified Hatches: Insulated Body Crane Year: Body Material # of Fuel Tanks: Liquid Control Meters # of Fuel Tanks: Crane Make: Steel Total Fuel Cap # gal: DOT Bumper Total Fuel Cap # gal: Crane Model: Aluminum Reefer Manufacture: Crane Cap: GRAIN TRUCK Scrubber Box Body Length (ft.): Body Year: Reefer Model: Crane Mount Type Emergency Valves Liner Body Manufacture: Reefer Hours: Front Mount Side Floats Air Dump Gate Body Material Cold Plate Mfg: Rear Mount Hoses Cold Plate Model: Heated Body Steel Aluminum Max Boom Ext: Hydraulic/Direct Drive Roll Tarp Stainless Steel Jib Extension: Hydraulic Direct Manual Power Body Length: Outriggers Dumping Hoist Box Type Pump Equipment Man Lift Equipment Pump Year: Elect/Hydraulic Grain Box Silage Box Man Lift Year: Pump Make: Box Extensions Man Lift Make: PTO Hydraulic Pump Model/Size: Roll Tarp Man Lift Model: PTO Wet Kit Tank Code/Use Man Lift Cap: Manual Power Pintle Hitch Crude Oil Fuel Max Lift Height: PTO/Hydraulic Hoist Yes Plumbed Water Food Grade # of Man Buckets Salt/Sand Spreader Gate Type Sewage 1 Man 2 Man Grain Gate Silage Gate Tailgate Spreader # of Fuel Tanks: Outriggers Slide-in V-Style Drill-Fill Hydraulics Total Fuel Cap # gal: Spreader Year: # of Fuel Tanks: Spreader Mfg: Total Fuel Cap # gal:

CONDITIONING: INTERIOR ABOVE AVERAGE AVERAGE BELOW AVERAGE Prior Damage Cost: $ EXTERIOR ABOVE AVERAGE AVERAGE BELOW AVERAGE Prior Damage Cost: $ MECHANICAL ABOVE AVERAGE AVERAGE BELOW AVERAGE ENGINE Rebuilt Engine Yes No Miles on Rebuilt: Cost: $ TRANS Rebuilt Trans Yes No Miles on Rebuilt: Cost: $ OTHER MECHANICAL RECEIPTS Desc/$: Date work done/Part(s): FRONT TIRES ABOVE AVERAGE AVERAGE BELOW AVERAGE REAR TIRES

1st AXLE ABOVE AVERAGE AVERAGE BELOW AVERAGE REAR TIRES