<p> Option/Condition Form Fax: (877) 771-8270 Administrative Information Approved for fax or upload Claim Number: Adjr. Last Name: 1st Name: Insured’s Name: Owner’s Name: Owner’s Phone #: Owner’s ZIP Code: State: Shop Email address: Fax Back to: 877-771-8270 VIN State: Loss Date: Year Make Model Body Style: 2DR 4DR Lift/Hatchback Convertible Wagon Pickup Van Utility ½Ton ¾Ton Shortbed Longbed Cab & Chassis Fleetside Fenderside Engine Detail Size: Cylinders: 3 4 5 6 8 12 10 Turbo Diesel Transmission AT S6 S5 S4 S3 O 4W POSI TRAC.CONT. D Mileage (‘UNK” if unknown) Power Options Seating Wire Wheel Covers Clearcoat Paint Power Steering Cloth Seats Rally Wheels Metallic Paint Power Brakes Leather Seats Locking Wheels Rear Spoiler Power Windows Reclining/Lounge Seats Locking Wheel Covers Fog Lamps Power Locks Bucket Seats Roof Tinted Glass Pwr. Drive Seat Heated Seats Electric Glass Roof Privacy Glass Pwr. Pass. Seat Rear Heated Seats Electric Steel Roof Body Side Moldings Power Antenna 3rd Row Seat Skyview Roof Dual Mirrors Power Mirrors Power 3rd Seat Dual Power Roofs Heated Mirrors Power Trunk/Tailgate Retractable Seats Manual Steel Roof Headlamp Washers Power Adjustable Pedals 12 Passenger Seating Manual Glass Roof Signal Integrated Mirrors Power Sliding Door 15 Passenger Seating Flip Roof Other And Trucks Dual Power Sliding Doors Captain Chairs (2) Soft Top Running Boards/Side Steps Décor/Convenience Captain Chairs (4) Hard Top Pwr Retracting Run. Boards Air Conditioning Captain Chairs (6) Safety/Brakes Xenon Headlamps Dual Air Conditioning Radio Driver Side Airbag Bed Rails Climate Control AM Radio Passenger Side Airbag Bed Liner (Drop-In) Rear Defogger FM Radio Front Side Impact Airbags Bed Liner (Spray-On) Intermittent Wipers Stereo Rear Side Impact Airbags Deluxe Truck Cap Tilt Wheel Cassette Head/Curtain Airbags Grill Guard Telescopic Wheel Search/Seek Theft Deterrent/Alarm Rear Step Bumper Cruise Control CD Player Night Vision Swivel Seats Keyless Entry CD Changer/Stacker Intelligent Cruise Rear Sliding Windows Console/Storage Premium Radio Parking Sensors Power Rear Window Overhead Console Satellite Radio Parking Sensors W/ Equip Tool Box (permanent) Entertainment Center Strg. Wheel Touch Control Anti-Lock Brakes (2) Soft Tonneau Cover Navigation System Aux. Audio Connection Anti-Lock Brakes (4) Hard Tonneau Cover Communication System Equalizer 4-Wheel Disc Brakes Trailering Package (Onstar, etc.) CB Radio Roll Bar Dual Rear Wheels Heads Up Display 8 Track Tape Player Traction Control Aux. Fuel Tank Wood Interior Trim Wheels Stability Control 3rd Truck Door Electronic Instrumentation Aluminum/Alloy Wheels Auto Level 4th Door Truck/Van On-Board Computer (police) Chrome Wheels Exterior/Paint/Glass Bumper Cushions Message Center 20” or Larger Wheels Luggage/Roof Rack Bumper Guards Memory Package Deluxe Wheel Covers Woodgrain CA Emissions Remote Starter Full Wheel Covers Rear Window Wiper Stone Guard Spoke Aluminum Wheels Two Tone Paint Winch Styled Steel Wheels Deluxe Two-Tone Paint Snowplow Package Wire Wheels Three Stage Paint Additional Options:</p><p>CONDITION RATING – REFER TO CCC CONDITION DESCRIPTORS Rate each of the following: R = Rough, F = Fair, C = Clean , E = Extra Clean COMMENTS Engine R F C E Transmission R F C E Paint R F C E Front Tires R F C E Rear Tires R F C E Body/Glass R F C E Interior R F C E</p>