Please complete the following form to request a vehicle damage appraisal.

Select the office to send this claim to	Select Location Campbell River Courtenay Duncan Nanaimo Port Alberni Powell River Vancouver Victoria Head Office for Sorting
From (Name)
Date
Sender (Company)
Phone
Email *required
Type of Loss
Date of Loss
Claim Number
Insured
Insured (Name)
Address
Telephone
Contact Name
Contact Telephone

Coverages

Policy Number
Term
Type of Policy
Agent
Deductible

Vehicle Information
Vehicle Make and Model
VIN Number
Licence Plate Number
Vehicle Location (home, name of shop etc)
Address
City
Phone Number
Claim Type	Collision Comprehensive
Deductible Amount
Replacement Cost
To Pay GST	Insured Third Party
Possible Write Off	Yes      No

Remarks

Image Verification
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Coast Claims Service Ltd. Head Office - Victoria Suite 6, 2727 Quadra Street, Victoria, BC V8T 4E5 Toll Free: 1-866-694-3111 Phone 250-386-3111 Fax 250-386-1473 Email: victoria@coastclaims.com