Order aform for a damage survey

Order procedure for a damage survey : step 1
Date:	4 December 2008
Client
Full name:(*)		Firstname:(*)
Street name:(*)		No.:(*)
Postcode:(*)		Town/city:(*)
Country:(*)		Tel.:(*)
Email:(*)		Fax:
Your Reference:
Owner or user
If the client and the owner or user are not one and the same person, some additional information should be given on the next page.		The owner/user is the client The owner/user is not the client.
Vehicle
Type of vehicle:(*)		Marque:(*)
Type/model:(*)		Number-plate:
Colour:		Year of manufacture:
Is the vehicle currently out of use?		Yes No
Does this relate to a contract hire vehicle?		Yes No
Nature of the damage or problem
Claim date or the date on which the problem arose :(*)
Description of your loss, damage or other problem:
Where is the vehicle right now?
Is the vehicle parked at the client’s address?		Yes No
Miscellaneous
In what capacity are we to act?
Is a damage appraiser already involved in filing the claim?		Yes No
Is a lawyer (or legal adviser) already involved in filing the claim?		Yes No
Is an insurance company already involved in filing the claim?		Yes No
Is an insurance broker already involved in filing the claim?		Yes No
Remarks to make:
To whom may the statement of fees be addressed?(*)

(*) This is a mandatory field. It must be completed in order to process your order correctly.