Car Wash Insurance Claim Form
Car Wash Insurance Claim Form
Please complete this form to file a claim for any damages caused during the car wash service.
Claimant Information
Name
Address
Phone number
Vehicle Information
Make and Model
Year
License Plate Number
Incident Description
Date of Incident
Type of Damage
Check all that apply.
-
Scratches
-
Dents
-
Broken Mirrors
-
Description of the Incident
Evidence
Please attach photographs of the damage (if available)
Insurance Policy Information
Insurance Provider
Policy Number
Claim Number (if applicable)
Signature
Claimant
Name:
Date:
Thank you for submission!
We appreciate you taking the time to submit.
Create free forms at Template.net
