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Street Address, City, State, and Zip Code*

Date of Accident/Damage

What happened to your vehicle?

Your Insurance Company

Deductible Amount

Insurance Claim Number

Are You the Insured or Claimant?

Insured

Claimant

Original Repair Estimate $ from Your Insurance Company

Insurance Photos Uploaded?

Yes

Vehicle Information: Year, Make, Model and Color

Mileage

Are you planning to get your repairs performed at Anderson's Autobody?

Are you shopping around for cost estimates?

How are you planning to pay for services?

Self Payment (if paying with a credit or debit card a 3% processing fee will be added to customer pay portion)

Another Person (not myself)

Insurance Company

Not sure

Upload 3-4 photo of the damage

Upload picture of your VIN Number on the driver's side dashboard (stand outside of the vehicle to take the pic)

How Did You Hear About Us?

Type your name and date (we will ask for an ink signature at the shop)

Customer Intake Form