Dummy Contact Page

Company Name

Date

Main Contact

Phone Number

Email Address

Branches

TypeChoose an item.CarrierTPAMGAFinancialOther

AdjustersChoose an item.Adjuster ListSingle AdjusterSingle Adjuster per Branch

Adjusters Attach

How will assignments be sent to IAnet?Choose an item.Audatex Claims ManagerCCCEmailEntegralFaxIAnet PortalMitchell Work CenterNUGEN ITOther

If other was selected, fill in information here:

How will completed reports be returned to the client?Choose an item.Audatex Claims ManagerCCCEmailEntegralFaxIAnet PortalMitchell Work CenterNUGEN ITOther

If other was selected, fill in information here:

File bundling requirements? Choose an item.No bundlingBundle all togetherSeparate out estimateSeparate out invoice

Does the estimate get released? Choose an item.Yes - Owner / ShopYes - OwnerYes - ShopNoSupplements Only

Mileage Approval Contact?

Will the carrier need our insurance certificate? Choose an item.yesNo

Send Certificate To:

Email

User Access Credentials To IAnet Portal & Services (Please List All Users)

Name

Email Address

Phone

Attachment

Complete Total Loss report when repair cost equals or exceeds:Choose an item.65%70%75%80%OtherDiscuss With Account Manager

If other was selected, fill in information here:

Total Loss Valuation SourceChoose an item.ADP AutosourceADP Autosource and DCIAverage of Dealer Quotes and BookCCCDCITotal Loss Valuation Source: Dealer QuotesNADANADA/Blue Book/Red Book-Average 2VVSDiscuss With Account Manager

If other was selected, fill in information here

Total Loss Valuation Options (check box):

No total loss handlingFill out form onlyObtain valuation using IAnet office ID# (Audatex, DCI, or VVS Only)Obtain valuation using company’s office ID# Type in ID# (Applies to All Sources)Discuss With Account ManagerOther

Do you have a guidelines manual? Choose an item.yesNo

Guidelines for LKQ part usage Choose an item.12 Months or 12,000 Miles24 Months or 24,000 MilesDo not useOtherDiscuss With Account Manager

Guidelines Attach

If other was selected, fill in information here

Parts Excluded

Guidelines for Aftermarket part usage: Choose an item.12 Months or 12,000 Miles (CAPA Certified sheet metal)24 Months or 24,000 Miles (CAPA Certified sheet metal)Do not useOtherDiscuss With Accout Manager

If other was selected, fill in information here:

Parts Excluded

Betterment/Depreciation:
Please list if company has specific instructions or attach Depreciation Schedule on separate page. If not, IAnet abides by state regulations and industry standards.
**This information should be placed on a separate page or in the notes section**

Billing Contact

Phone Number

Email Address

Invoicing Details Choose an item.Bulk billing - watermarked invoice sentBulk billing - no invoice sentInvoice to AdjusterInvoice to Specific Email Address

Invoice Email Address

MA / CA DOI Reporting YesNo

Massachusetts & California DOI Reporting: (DOI reports are ran quarterly unless the carrier wants something different) Does the client need a Massachusetts & California DOI report emailed to them? Choose an item.YesNo

At what frequency? Choose an item.MonthlyQuarterly

Will you need IAnet to reopen completed files to complete a DOI reinspection? Choose an item.YesNo

Massachusetts &CA DOI Contact:

Phone Number

Email

Salvage pool or contract buyer YesNo

Company Name

Contact Person

ID#

Phone

Fax:

Email

Additional Notes