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Name*
First Last
Phone*
Email*
Year*
Make*
Model*
2 Close Up Pictures of Damage*
Take one picture from the left side of the damage and one picture from the right side.
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2 Farther Back Pictures of Damage*
Take one picture from the left side of the damage and one picture from the right side.
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Picture of VIN Tag*
Picture of The Rear of Car*
Additional Comments About Damage
Who Will Be Paying for Repairs?*

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