Form CSD-005 "Auto Body Repair Shop Report Form" - California

What Is Form CSD-005?

This is a legal form that was released by the California Department of Insurance - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 18, 2020;
  • The latest edition provided by the California Department of Insurance;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form CSD-005 by clicking the link below or browse more documents and templates provided by the California Department of Insurance.

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Download Form CSD-005 "Auto Body Repair Shop Report Form" - California

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STATE OF CALIFORNIA
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Ricardo Lara, Insurance Commissioner
DEPARTMENT OF INSURANCE
CONSUMER SERVICES AND MARKET CONDUCT BRANCH
300 SOUTH SPRING STREET, SOUTH TOWER
LOS ANGELES, CA 90013
www.insurance.ca.gov
CSD-005
Revised: 12/18/2020
AUTO BODY REPAIR SHOP REPORT FORM
Name of Automobile Body Repair Shop:
Business Phone:
Name and Position of Person Reporting:
Address:
Contact Email Address:
City:
State:
ZIP:
1.
Complete name of insurance company involved:
Yes ☐
No ☐ If Yes, Skip to Question 8.
2.
Are you reporting a denial in an insurer’s Direct Repair Program?
3.
Type of Insurance: AUTO
4.
Name and Address of the policyholder/claimant/customer:
5.
Policy identification number:
6.
Claim number:
7.
Date loss occurred or began:
8.
Name of Adjuster or Insurance Company Representative:
Have you reported this to any other governmental agency? Yes ☐
No ☐
9.
If yes, Please give the
Name of the Agency: _________________________File number, if known: ______________________
10. Have you previously written to the California Department of Insurance about this matter? Yes ☐
No ☐
File number (if available) _________________________ Date submitted _____________________
11. Briefly, describe the details of the transaction and provide any documentation to support your allegations.
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
______________________________________________
__________________________________________
Signature
Date
STATE OF CALIFORNIA
~
r
-,
~
'
-
-
I
Ricardo Lara, Insurance Commissioner
DEPARTMENT OF INSURANCE
CONSUMER SERVICES AND MARKET CONDUCT BRANCH
300 SOUTH SPRING STREET, SOUTH TOWER
LOS ANGELES, CA 90013
www.insurance.ca.gov
CSD-005
Revised: 12/18/2020
AUTO BODY REPAIR SHOP REPORT FORM
Name of Automobile Body Repair Shop:
Business Phone:
Name and Position of Person Reporting:
Address:
Contact Email Address:
City:
State:
ZIP:
1.
Complete name of insurance company involved:
Yes ☐
No ☐ If Yes, Skip to Question 8.
2.
Are you reporting a denial in an insurer’s Direct Repair Program?
3.
Type of Insurance: AUTO
4.
Name and Address of the policyholder/claimant/customer:
5.
Policy identification number:
6.
Claim number:
7.
Date loss occurred or began:
8.
Name of Adjuster or Insurance Company Representative:
Have you reported this to any other governmental agency? Yes ☐
No ☐
9.
If yes, Please give the
Name of the Agency: _________________________File number, if known: ______________________
10. Have you previously written to the California Department of Insurance about this matter? Yes ☐
No ☐
File number (if available) _________________________ Date submitted _____________________
11. Briefly, describe the details of the transaction and provide any documentation to support your allegations.
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
______________________________________________
__________________________________________
Signature
Date
Ricardo Lara, Insurance Commissioner
STATE OF CALIFORNIA
DEPARTMENT OF INSURANCE
Privacy Notice on Information Collection
Request for Assistance Forms
*** This notice is provided pursuant to the Information Practices Act of 1977 (California Civil Code Section 1798.17) ***
Collection and Use of Personal Information
California Insurance Code Sections 12921 and 12921.1, and related statutes and regulations, give the
California Department of Insurance (CDI) and the Consumer Services Division the authority to regulate and
investigate consumer complaints. The CDI uses your information to address complaints brought to the
Department’s attention. Information is collected subject to limitations contained in the Information Practices Act
of 1977, SAM 5300, et seq., SIMM 5305, et seq., and other applicable state and federal laws.
Providing Personal Information Is Voluntary
You do not have to provide the personal information requested. However, if you do not wish to provide us the
necessary information, we may not be able to investigate your complaint. When providing information or
documents, please do not include unrequested personal information, such as Social Security Numbers,
Driver’s License Numbers, unnecessary health-related information, and credit card or financial information.
Information Provided to CDI Is Confidential
All information you provide to us during the investigation of your complaint will be treated as a confidential
communication under California Insurance Code Section 12919. We will not disclose any information to any
person outside CDI, unless otherwise permitted or required by law.
Possible Disclosure of Personal Information
We may share your personal information with the insurance licensee and in the case of an Independent Medical
Review with the Independent Medical Review Organization. We may also share your information with other
government or regulatory agencies as permitted or required by law, or pursuant to Memorandum of
Understanding.
Access to Your Information
You have the right to access records containing your personal information which are maintained by CDI. To
request access, contact: CDI Privacy Officer, Legal Division, Government Law Bureau, 300 Capitol Mall, Suite
1700, Sacramento, CA 95814, (916) 492-3500.
Department Privacy Policy
The California Department of Insurance has developed policies regarding the privacy of your information. They
may be viewed at www.insurance.ca.gov/privacy-policy.
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