Recreational Vehicle Basic Claim Information Form

CRV Office ID#:

Report Retrieval Email Fax Other (Specify): Method Claim Representative Claim Claim Representative Name: Representative Contact #: Email: ( ) -

Date of Loss Claim #: Policy #: Type of (mm/dd/yyyy): Loss:Collision

Insured Name: Insured Phone #: Claimant Name: Claimant Phone #:

Loss State: Loss Zip Code:

VIN: Recreational Vehicle Basic Claim Information Form

Year:Power Options Convenience Make:Seat/Interior Model:Other Power Steering Cruise Control Cloth Seats Body Side Moldings Body Type: Chassis Year: Transmission: Leveling System: Power Brakes Tilt Wheel Leather Seats Running Boards/Side Conversion Van ______Automatic Manual Yes No Power Windows Air Conditioning Swivel/Captains Chairs Step Power Locks Auxiliary AC Odometer:Split Bench Seats Trailer Hitch Length: Chassis Suspension: Power Driver Seat Auxiliary Heater Bucket Seats Trailering Package ______Manufacturer: Engine Manufacturer: Spring Power Passenger Seat Swamp Cooler Reclining Lounge Seats Pinstriping Doors: ______Power Antenna Furnace ______Fold-out Sofa Bed AirTwo Ride Tone Paint ______Chassis Model: Power Mirrors Gas Electric Power: Yes No Metallic Paint ______Engine Model: ______Mor-Ryde Ducted: Yes No Wood Trim Custom Paint # of Axles: Roof Options Auxiliary Fuel TankEngine Size:Full Carpeting______OtherCustom Windows ______Standard Roof Keyless Entry Insulated Walls w/ Draperies/Mini Blinds # of Slideouts: # of Awnings: ______Electrical: Rebuilt Engine: Yes No Raised Roof Theft Deterrent Paneling Center Mount Game ______Luggage/Roof Rack AwningInfinity Length: Sound Upholstered Door Panels MilesTable on Rebuilt______110 Volt Skylight Roof Intermittent Wipers Interior Lighting Tire Rack/Carrier Power Manual ____ ft. Cost of Rebuilt $______Air Vent Fog Lamps 12 VoltLighted Drink Tray Solar Panel LengthFlip of Roof Slideouts: Cellular Phone Console/Storage Rebuilt# of Solar Transmission: Panels ______Yes AC/DC Converter Length of Awnings: Overhead Console Driver’s Side Door 1st______ft. No Wheels 1st______ft.Electronics InverterPower Yes No Spare Tire 2nd______ft.Aluminum/Alloy Television Kitchen/Bath MilesPropane on Rebuilt______Tank 2nd______ft. ______Watts Wheels Size ______inches Stove/Oven Water Heater 3rd______ft. Cost of Rebuilt $______Spoked Aluminum 3rd______ft.VCR Monitor PanelGas Electric Water Storage Wheels Game System Microwave Washer/Dryer Electric Steps: Generator Syled Steel Wheels Electronic Hookups Refrigerator Central Vacuum Wire Wheels SingleAM Double ______Watts Gas Electric Chrome Wheels FM Side by Side Levelers Triple ______# of House Rally Wheels ST Side by Side w/ Manual Stab Jacks Aluminum Wire CA BatteriesIcemaker Electric Screw Wheels Seek/Scan Water Purifier Hydraulic Ram Wire Wheel Covers CD Garbage Disposal Computer Controlled Custom Wheels CB Radio Ice Box Equalizer Sink Tongue Jack CD Changer Stacker Full Bath Manual Electric Dual Stereo Half Bath Holding Jack Satellite Dish Grey Water In Motion Manual Safety Waste Water DVD Air Bag Fresh Water Passenger Air Bag #LPG______Front Side Air Bag #Fuel______4 Wheel Disc Brakes Rearview Monitor

Overall Condition Rating: (1) Below Average (2) Average (3) Exceptional

Additional Equipment (include price if applicable):

Pre Tax Adjustment: Add: Deduct: Recreational Vehicle Basic Claim Information Form

Pre Tax Adjustment: Add: Deduct: Sales Tax %: Deductible: Post Tax Adjustment: Add: Deduct: Post Tax Adjustment: Add: Deduct:

Notes: