Minot
Insurance Company
Submission Form
Minot Dakota Salvage Pool
420 41st St SE
Minot, ND 58701
(701) 839-5392
(701) 838-0705 -Fax
Please fill in all boxes.
Can List:
Yes
No
Title Sent:
Yes
No
Damage Disclosure:
Insurance Company:
Adjuster's Name:
Person To Contact:
Phone Number:
Date Submitted:
Date Picked Up:
Vehicle Owner:
Year Of Vehicle:
Vehicle Make:
Vehicle Model:
Vehicle Color:
Vehicle VIN #:
Date Of Loss:
Claim #:
Vehicle Location:
Outside Tow Bill:
Actual Vehicle Value:
Vehicle Milage:
Vehicle Damage:
Where Are Keys:
Is Vehicle Towable:
Yes
No
Listing Fee:
