Dashboard - Blake Information Solutions



|Option/Condition Form |Fax: (877) 771-8270 | |

|Administrative Information |Approved for fax or upload |

|Claim Number: | |Adjr. Last Name: | |1st Name: | |

|Insured’s Name: | |Owner’s Name: | |

|Owner’s Phone #: | |Owner’s ZIP Code: | |State: | |

|Shop Email address: | |Fax Back to: |877-771-8270 |

|VIN | |

|Power Options |Seating | |Wire Wheel Covers | |Clearcoat Paint |

| |Power Steering | |Cloth Seats | |Rally Wheels | |Metallic Paint |

| |Power Brakes | |Leather Seats | |Locking Wheels | |Rear Spoiler |

| |Power Windows | |Reclining/Lounge Seats | |Locking Wheel Covers | |Fog Lamps |

| |Power Locks | |Bucket Seats |Roof | |Tinted Glass |

| |Pwr. Drive Seat | |Heated Seats | |Electric Glass Roof | |Privacy Glass |

| |Pwr. Pass. Seat | |Rear Heated Seats | |Electric Steel Roof | |Body Side Moldings |

| |Power Antenna | |3rd Row Seat | |Skyview Roof | |Dual Mirrors |

| |Power Mirrors | |Power 3rd Seat | |Dual Power Roofs | |Heated Mirrors |

| |Power Trunk/Tailgate | |Retractable Seats | |Manual Steel Roof | |Headlamp Washers |

| |Power Adjustable Pedals | |12 Passenger Seating | |Manual Glass Roof | |Signal Integrated Mirrors |

| |Power Sliding Door | |15 Passenger Seating | |Flip Roof |Other And Trucks |

| |Dual Power Sliding Doors | |Captain Chairs (2) | |Soft Top | |Running Boards/Side Steps |

|Décor/Convenience | |Captain Chairs (4) | |Hard Top | |Pwr Retracting Run. Boards |

| |Air Conditioning | |Captain Chairs (6) |Safety/Brakes | |Xenon Headlamps |

| |Dual Air Conditioning |Radio | |Driver Side Airbag | |Bed Rails |

| |Climate Control | |AM Radio | |Passenger Side Airbag | |Bed Liner (Drop-In) |

| |Rear Defogger | |FM Radio | |Front Side Impact Airbags | |Bed Liner (Spray-On) |

| |Intermittent Wipers | |Stereo | |Rear Side Impact Airbags | |Deluxe Truck Cap |

| |Tilt Wheel | |Cassette | |Head/Curtain Airbags | |Grill Guard |

| |Telescopic Wheel | |Search/Seek | |Theft Deterrent/Alarm | |Rear Step Bumper |

| |Cruise Control | |CD Player | |Night Vision | |Swivel Seats |

| |Keyless Entry | |CD Changer/Stacker | |Intelligent Cruise | |Rear Sliding Windows |

| |Console/Storage | |Premium Radio | |Parking Sensors | |Power Rear Window |

| |Overhead Console | |Satellite Radio | |Parking Sensors W/ Equip | |Tool Box (permanent) |

| |Entertainment Center | |Strg. Wheel Touch Control | |Anti-Lock Brakes (2) | |Soft Tonneau Cover |

| |Navigation System | |Aux. Audio Connection | |Anti-Lock Brakes (4) | |Hard Tonneau Cover |

| |Communication System | |Equalizer | |4-Wheel Disc Brakes | |Trailering Package |

| |(Onstar, etc.) | | | | | | |

| | | |CB Radio | |Roll Bar | |Dual Rear Wheels |

| |Heads Up Display | |8 Track Tape Player | |Traction Control | |Aux. Fuel Tank |

| |Wood Interior Trim |Wheels | |Stability Control | |3rd Truck Door |

| |Electronic Instrumentation | |Aluminum/Alloy Wheels | |Auto Level | |4th Door Truck/Van |

| |On-Board Computer (police) | |Chrome Wheels |Exterior/Paint/Glass | |Bumper Cushions |

| |Message Center | |20” or Larger Wheels | |Luggage/Roof Rack | |Bumper Guards |

| |Memory Package | |Deluxe Wheel Covers | |Woodgrain | |CA Emissions |

| |Remote Starter | |Full Wheel Covers | |Rear Window Wiper | |Stone Guard |

| | | |Spoke Aluminum Wheels | |Two Tone Paint | |Winch |

| | | |Styled Steel Wheels | |Deluxe Two-Tone Paint | |Snowplow Package |

| | | |Wire Wheels | |Three Stage Paint | | |

|Additional Options: |

| |

|CONDITION RATING – REFER TO CCC CONDITION DESCRIPTORS |

|Rate each of the following: R = Rough, F = Fair, C = Clean , E = Extra Clean COMMENTS |

|Engine | |R | |F | |C | |E | |

|Transmission | |R | |F | |C | |E | |

|Paint | |R | |F | |C | |E | |

|Front Tires | |R | |F | |C | |E | |

|Rear Tires | |R | |F | |C | |E | |

|Body/Glass | |R | |F | |C | |E | |

|Interior | |R | |F | |C | |E | |

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