Save-A-Car Request Form

Body & Paint Shop Information
Company Name *
Contact Person *
E-Mail Address *
Telephone No. *

Vehicle Details
Vehicle Model *
Vehicle Reg. No. *
Vehicle VIN No. *
Vehicle Value *
Write-Off Threshold *
Estimate Vehicle Repair Total *
% Repair needs to reduce to save vehicle

Dealership Information
Dealership Province *
Dealership *
Dealer Code
Dealer Principal *
Dealer Parts Manager *
Manager E-Mail Address *
Dealer Contact Person (if different to above) *
Dealer E-Mail Address *
Dealer Contact Number *

Insurer Details
Insurance Company Used
Insurance Company Used
Insurance E-Mail Address *

Quates to attach

Please enter part numbers as entered on the Dealer invoice only

Part Code* Quoted Price (to Insurance Company)* Dealer Price*