Physical Damage Inspection/Mechanical Statement Report Form - American Freedom Insurance Company - Illinois

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American
Freedom
PHYSICAL DAMAGE INSPECTION/
Insurance Company
MECHANICAL STATEMENT REPORT
559 W. Golf Rd.
Arlington Heights, IL 60005
Named Insured
Policy No.:
Address
Producer:
City, State, Zip
VEHICLE INFORMATION
Year:
Make/Model:
Doors
VIN:
Color:
Odometer
FOR PHYSICAL DAMAGE COVERAGE, conduct a visual inspection of the vehicle and indicate on the illustration the areas where any damage
exists, such as dents, holes, chips, scratches, rust, etc. Give special attention to bumpers, windshields and condition of paint. Describe any
present damage in the space provided below.
MECHANICAL STATEMENT
Must be signed by a certified mechanic shop
MECHANICAL INFORMATION
ACCESSORIES AND OPTIONAL EQUIPMENT
Tire condition good
Yes
No
Air Conditioner
Yes
No
Brakes working properly
Yes
No
Anti-Theft Device
Yes
No
Headlights working
Yes
No
Automatic Transmission
Yes
No
Tail lights working
Yes
No
Bucket Seats
Yes
No
Engine in good condition
Yes
No
CB Radio
Yes
No
Custom Wheels
Yes
No
Customized Body
Yes
No
Heated Seats
Yes
No
Leather Seats
Yes
No
Navigation System
Yes
No
Power Seats
Yes
No
Power Steering/Brakes
Yes
No
Power Windows
Yes
No
Radio – AM/FM Stereo Cassette – CD Player
Yes
No
Special Packages
Yes
No
Special Tires
Yes
No
Sunroof
Yes
No
Tinted Glass
Yes
No
Vinyl Top/Special Roof
Yes
No
Aftermarket Items (please list)
Name of shop:
Address:
Inspected by:
Date:
American
Freedom
PHYSICAL DAMAGE INSPECTION/
Insurance Company
MECHANICAL STATEMENT REPORT
559 W. Golf Rd.
Arlington Heights, IL 60005
Named Insured
Policy No.:
Address
Producer:
City, State, Zip
VEHICLE INFORMATION
Year:
Make/Model:
Doors
VIN:
Color:
Odometer
FOR PHYSICAL DAMAGE COVERAGE, conduct a visual inspection of the vehicle and indicate on the illustration the areas where any damage
exists, such as dents, holes, chips, scratches, rust, etc. Give special attention to bumpers, windshields and condition of paint. Describe any
present damage in the space provided below.
MECHANICAL STATEMENT
Must be signed by a certified mechanic shop
MECHANICAL INFORMATION
ACCESSORIES AND OPTIONAL EQUIPMENT
Tire condition good
Yes
No
Air Conditioner
Yes
No
Brakes working properly
Yes
No
Anti-Theft Device
Yes
No
Headlights working
Yes
No
Automatic Transmission
Yes
No
Tail lights working
Yes
No
Bucket Seats
Yes
No
Engine in good condition
Yes
No
CB Radio
Yes
No
Custom Wheels
Yes
No
Customized Body
Yes
No
Heated Seats
Yes
No
Leather Seats
Yes
No
Navigation System
Yes
No
Power Seats
Yes
No
Power Steering/Brakes
Yes
No
Power Windows
Yes
No
Radio – AM/FM Stereo Cassette – CD Player
Yes
No
Special Packages
Yes
No
Special Tires
Yes
No
Sunroof
Yes
No
Tinted Glass
Yes
No
Vinyl Top/Special Roof
Yes
No
Aftermarket Items (please list)
Name of shop:
Address:
Inspected by:
Date:

Download Physical Damage Inspection/Mechanical Statement Report Form - American Freedom Insurance Company - Illinois

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