NAME		Has the vehicle been involved in an accident?
			Select One Yes No
	STATE     PHONE		Was the accident your fault?
			Select One Yes No
	E-MAIL
			Has the vehicle been repaired?
			Select One Yes No
	YEAR       MAKE		COST OF REPAIRS
	MODEL		Are you satisfied with the repairs?
			Select One Yes No
	MILEAGE
			Insurance Company
	VIN NUMBER
			The insurance company's response to your claim?
			Select One Have not made claim yet Offered less than I expected Will send their appraiser If vehicle is repaired DV is NOT owed Company does NOT pay DV DV is NOT owed Company does NOT think DV exists