ONLINE BOOKING  
 
 
1. Customer Information

Name:
Address:
City:
Province:
Postal Code:
Telephone (W):
Telephone (H):
Email:

The best time to contact AM PM
The best way to contact Telephone Email

2. Vehicle Information

Year: Make:

Model:

License Plate:

Colour: Style
(2 or 4 Door):

Do you have an insurance claim?
Yes No (If no, please go to Item 3 - Miscellaneous)

If yes, please answer the following questions:

Name of Insurance Company:
Claim Number:
Adjuster's Name:
Were you at fault in the accident? Yes No
What is your deductible?
Date of Accident
Do you have loss of use coverage? Yes No
Police Accident Case Number

3. Miscellaneous

How did you hear about us?

Repeat customer Customer Referral Insurance Referral
TV Ad Radio Ad Newspaper
Driving By Building Sign Yellow Pages
Web Site

Do you have the ability to email a digital image of the damage on your vehicle? Yes No
Do you require a replacement vehicle? Yes No

Comments:

Thank you for taking the time to book your service appointment on-line.