NOTE: A Copy of the Estimate must be submitted together with this Mitsubishi form! Mitsubishi

Mitsubishi Save-A-Car Request Form

Fields with * indicate mandatory information. Please complete All fields in order to submit.

Motor Body Repairer 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
Date Parts Ordered Pick a date

Dealership Information
Dealership Province *
Dealership *
Dealer Code
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 *
Assessor Contact Number *
Insurance E-Mail Address *

Additional Information
PART CODE* QUOTED PRICE* DEALER PRICE*