NOTE: A Copy of your Quotation and Dealer Quotation must be submitted together with this Ford form! FORD

Total Loss Avoidance Request

Fields with * indicate mandatory information. Please complete All fields in order to submit.
Panel Shop Name *
Panel Shop Contact Person *
E-Mail Address *
Telephone No. *
Vehicle Model *
Vehicle Reg. No. *
Vehicle VIN No. *
Vehicle Value *
Write-Off Threshold (Incl. VAT) *
Estimate Vehicle Repair Total (Incl. VAT) *
% Repair needs to reduce to save vehicle
Dealership Province *
Ford Dealership *
Dealer Code
Dealer Parts Manager *
Manager E-Mail Address *
Dealer Contact Person (if different to above) *
Dealer E-Mail Address *
Insurance Company Used *
Insurance Contact Person *
Insurance E-Mail Address *
NOTE: A Copy of your Quotation and Dealer Quotation must be submitted together with this Ford form!
NOTE: All parts listed must correspond to your quotation to the Insurance Company

PART NUMBER* DEALER QUOTED PRICE (Excl. VAT)* QUANTITY REQUIRED*