Mechanical Statement Report/ Physical Damage Inspection
Client Name
Contact
Named Insured
Policy No.
Address
Producer
Vehicle Mileage upon Pick up
Vehicle Mileage upon Drop off
Fuel Level
Fuel Type
Driver Name
Driver ID NUMBER
Driver Driving license Expiry date Picture attachment
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Car Owners ID/Passport Upload
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Pick up location
Drop Off location
Year
Car Make
No. of Doors
VIN
Colour
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.
Front Image of the car/vehicle/automobile
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Left Image of the car/vehicle/automobile
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Rear Image of the car/vehicle/automobile
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Right Image of the car/vehicle/automobile
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MECHANICAL INFORMATION
Tire Condition good
Yes
No
Tail lights working
Yes
No
Headlights working
Yes
No
Brakes working properly
Yes
No
Engine in good condition
Yes
No
Air Conditioner
Yes
No
Ant Theft Device
Yes
No
Automatic Transmission
Yes
No
Bucket Seats
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 - AMFM 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
List aftermarket items
Any other information necessary.
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