Auto Collision Rebuilder Inc.

TEL: 847-221-2323

FAX: 847-221-2333

246 N. Woodwork Lane | Palatine, IL 60067

Let us assist with your claim...
Please fill out the following form with as much information as possible, so that we can
contact you, and further assist you.


*First Name:	Insurance:
*Last Name:	Insurance Company:
*E-mail:	Insurance Agent Name:
Address:	Insurance Agent Phone Number:
City:	Insurance Agent Fax Number:
State:	Claim Filed:	YES NO
Zip Code:	Claim Adjuster:
*Daytime Phone:	Claim Adjuster Phone Number:
Cell Phone:
Type of Car:
Vehicle Make:	Driveable:	YES NO
Vehicle Model:	If non-driveable, would you like A.C.R. to pick it up?	YES NO
Year:
License Plate Number:
Color of Car:
Area of impact: 1 2 3 4 5 6 7 8 9 10 11 12 13


Any other details you would like to provide:

A.C.R. SERVICES THE FOLLOWING AREAS Palatine, IL \| Arlington Heights, IL \| Schaumburg, IL \| Mount Prospect, IL \| Wheeling, IL \| Inverness, IL Barrington, IL \| Rolling Meadows, IL \| Deer Park, IL \| Hoffman Estates, IL \| Elgin, IL \| Chicago, IL & More...
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