New Customers

Save time during your vehicle drop-off! Complete this form for us before you arrive.

Customer Information

Name:

Date:

Address:

Phone:

Mobile:

City:

Email:

State:

Zip:

Customer Repair/Insurance Information

We request this information so that we will be able to provide the best possible customer service and quality repair.

1. How did you hear about us?

Repeat Customer

Drive-In

Yellow Pages

Insurance Agent

Insurance Company:

Auto Dealer

Referred to me by:

Other:

2. Who is paying for this repair?
My Insurance Their Insurance Myself

3. Can we assist you in processing your insurance claim?
Yes No

4. We will need the following information regarding the responsible insurance party:

Name of Insurance Company Paying for Repairs:

NOTE: Please call us to let us know the Agent's Name and Phone Number, Claim Number and Policy Number.

5. Has the insurance company inspected your vehicle and written a Damage Report? Yes No

6. Will you need a rental car? Yes No

7. What is your major concern in having your vehicle repaired?

Vehicle Information

Alliance Collision | MAP
1940 Placentia Ave. Costa Mesa,
CA 92627

Call: 949-631-5100

Fax: 949-631-5169

Alliance Collision Bodycraft | MAP
1306 Logan Ave. Costa Mesa,
CA 92626

Fax: 714-957-1231