Auto Collision Appraisal Service

Appraisal Service Request Form

Melvin Bantilan
P.O. Box 4059
Kahului, HI 96733
(808) 893-0660
Fax: (808) 873-7985

 
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Please fill in the following information. Incomplete forms will delay your service.
Company Name
Submitter Name
  
Claim Number
Date of Loss
  
Adjuster Name
  
Phone Number
Email
Fax Number
Type of Assignment
Full Appraisal
Photos Only
ACV Only
Type of Claim
Insured

Claimant
Deductible
Insured Name
Address
City
State
Zip
Home Phone Number
Work Phone Number
Vehicle Information
Year
Make
Model
Color
VIN
License Plate
Vehicle Location
Damage
Special Instructions
Would you like a confirmation of receipt of this assignment?
Yes
No
Where should we send the confirmation?
Mail
 Please provide address below.
Fax
to number above
Email
to address above
Other
 Please indicate below.
   
     
Send It In
Make Changes
 

Auto Collision Appraisal Service
Melvin Bantilan
P.O. Box 4059
Kahului, HI 96733
(808) 893-0660
Fax: (808) 873-7985

 
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