Autobody Craftsman Association

Report of Insurance Impropriety

When did the accident happen?

Where did it happen?

Where was your vehicle taken?

How did you notify your insurance company?

At a Claims Drive In
Called a telephone claims center
Told my agent
other (explain below)

What agent did you talk to and from what Insurance Company?

What were you told to do?

Did you make a request to take your vehicle to a different shop and why?

HOW WERE YOU HARMED as a result of this experience?

Printed Name

Notarized Signature_________________________	NOTARY PUBLIC in and for ____________County,________
	residing at__________________ my commission expires / / .
Have your statement notarized at a financial institution or any Notary Public.

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