DIMINUTION OF VALUE FORM

INSURED: «Enter Insured Full Name»	CLAIM #: «Enter Claim Number»
CLAIMANT: «Enter Claimant First Name» «Enter Claimant Last Name»	VEHICLE: «Enter Vehicle Year» «Enter Vehicle Make»
VIN #: «Enter Vehicle Identification (VIN)»	MILEAGE:
TOTAL REPAIR COST:	QUALITY OF REPAIR: Excellent Good Fair Poor
DATE INSPECTED:	INSPECTED BY:

USE OF FORM: This form is only to be used for standard passenger vehicles and trucks less than 10 years old and with less than 100,000 miles showing on the odometer. This form is not to be used with luxury vehicles or with specialty vehicles for which the market recognizes a premium, such as collector’s cars.

Condition of vehicle prior to loss	E G F P	Actual Cash Value: $
Were repairs completed per appraisal	Y N	Add for low mileage: $ Deduct for high mileage: $
Could an average person determine there has been previous repairs	Y N	Deduct for old damage: $
Has vehicle been restored back to pre-accident condition	Y N	Net ACV: $
Were all OEM parts used	Y N	Multiply x 10% $
Were any after market parts used	Y N	Damage Severity: 0.25 Minor Damage 0.75 Heavy Damage 0.50 Moderate Damage 1.0 Major Damage Multiply x above multiplier $
Were any LKQ parts used	Y N	Factor Mileage Modifier: 100,000 miles - current miles x % = mileage modifier % x $
Estimated Diminution of Value: $

Appraiser’s Comments: