Specialized Claims Synergy

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One Claim At A Time™

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Diminished Value Request Form

* Our staff will call you within 24 business hours after completion of this form. Fee collected at time of call.

Your Name:

Vehicle Owner Name:

Telephone#:

Address:

City:

State:

Zip Code:

Email Address?:

Claim#(if applicable):

Date of Loss:

Adjuster Name:

Insurance Company:




Vehicle Year:

Vehicle Make:

Vehicle Model:

Vehicle VIN:

Primary Area of Impact:

Final Repair Cost: $

Odometer:

Repair Quality:

First Accident for Vehicle:

All Repairs Complete?:

Overall Vehicle Condition:

Inspection Needed?

Additional Information:

Please upload a ZIP FOLDER with: Final Repair Estimate(mandatory); any photos of vehicle before loss(if available); any photos with accident damage(if available); any photos after repairs(if available); Carfax report if ran/available: