Name *

First Name

Last Name

Phone

(###)

###

####

Did an insurance company pay to have your car repaired in the previous year?

Yes

No

Was the bill paid by your insurance company or the at-fault party's insurance company?

My insurance Co.

The At-Fault Driver's Insurance Co.

Did you select the shop, or did the insurance company recommend one for you?

I selected the shop

My insurance company recommended the shop

Did they inform you that you could select any repair facility you wanted?

Yes

No

Were aftermarket part used in the repair?

Yes

No

I Don't Know

If aftermarket parts were used did you give permission?

Yes

No

I Don't Know

Are you happy with the overall repair?

Yes

No

Are you still experiencing issues you believe are related to the accident?

Yes

No