Micro Repair Appointment Form

INFORMACE O POJIŠTĚNÍ

Insurance Company:

Policy Number:

Policy Expire Date:

INFORMACE O PROHLÍDCE

Requested Appointment Date:

City:

INFORMACE O VOZIDLE

Plate Number:

Brand:

Model:

Model Year:

INFORMACE O ŠKODĚ

* Please upload two photoes for each damage panel. One close range photo and one wide range photo are requiered to make a certain damage analysis.

Damaged Panel:

Size of the Damage:

Damage Panel Photo (1):

Damage Panel Photo (2):

Repair Request Explanation: