THE UNITED INSURANCE COMPANY SC.

POST RISK SURVEY REQUEST

To : Engineering
From: Claims Division
Name of Insured: ____________________________________
Date of Accident: _________________________ Claim No.: _______________________
Survey Requested Date (by the insured or Garage): _______________________
Date of delivery at wreckyard (if applicable): _____________________________
Type of Survey: ____________________ (1st, 2nd,____________, Finalization, etc)

Appointment Given
Item Description (Pl. No.,.. ) Place of Survey Telephone No. Date Time

Remark (if any): _______________________________________________________________

___________________________________________________________________________

Survey requested by:Name/Signature _______________________/______________ _________________

Date

Assigned Surveyor: _______________ _____________ _______________ _____________

Name Assigned date Signature Date

POST RISK SURVEY REQUEST

To : Engineering
From: Claims Division
Name of Insured: ____________________________________
Date of Accident: _________________________ Claim No.: _______________________
Survey Requested Date (by the insured or Garage): _______________________
Date of delivery at wreckyard (if applicable): _____________________________
Type of Survey: ____________________ (1st, 2nd,____________, Finalization, etc)

Appointment Given
Item Description (Pl. No.,.. ) Place of Survey Telephone No. Date Time

Remark (if any): _______________________________________________________________

___________________________________________________________________________
Survey requested by:Name/Signature _______________________/______________ _________________
Date

Assigned Surveyor: _______________ _____________ _______________ _____________

Name Assigned date Signature Date
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