Claim No.: Insured: D/L:
Actual cash value or replacement cost? :
No.: Description: Location:
Replacement cost: Quantity: Repair cost (item):
If ACV applies, enter the useful life and enter the age of the item:
Enter salvage value if any: and amount of any betterment:
Adjusted value of item:
Total:
Search for price/supplier. Enter a precise description:
Apply the deductible to the total.