SCA Recreational Vehicle - Identification Form

Claimant Name Claimant Phone # License #Market Area (City/Zip/Postal Code)

Ext. Color VIN

Year Make Series Model Doors Chassis Mfg.

Slide Out Bedroom Odometer Trans.# of Rear AxlesSlide Out Living Area Length Engine Size # CylindersYes No No Auto Manual

CHECK

COMP

VEHICLE EQUIPMENTSUSPENSIONMISCELLANEOUSCAB ACCESSORIES GALLEYLIVING AREA

Power Steering (PS) MicrowavePeople MAIN AWNINGSleeps # SpringPower Windows (PW) Convection Oven Electric Manual Air Ride# Fulltime Beds

Mor-RydePower Locks (PL) Stove# of Couches # Window AwningsSlide-Out AwningPower Seats Oven Other# of Chairs

Leather Seats Dinette Screen Room EXTERIOR SKINRefrigerator# of TV's Gas Trader Hitch Steel# Captain Chairs

Cruise Control (CC) Sizes Electric AluminumLuggage Rack / LadderLCD Color Battery Roof Storage Pod FiberglassTilt Wheel (FW)

Dash Air Cond Rem Mount Tire Carrier SUPERSTRUCTURESeparate VCR Ice Box (non powered)Ice Maker Satellite Dish Steel# Roof Air Cond. Separate DVD

TV/VCR Combo Water Purifier In Motion Manual AluminumSwamp CoolerHome Stereo Rem View Video Camera WoodDrivers Door (Class A Garbage Disposal

Cass Food Processor LEVELERS# of Solar PanelsOption)Built-in Blender

AM/FM StereoCD Manual Stab JacksElectric Step

Built-in Coffee MakerCass

Double Electric ScrewCD Changer Single

CDCentral VacuumEqualizer Hydraulic Ram

HEATING Custom WheelsCD Changer

Computer ControlledELECTRICAL Furnace SS Wheel Liners

TONGUEJACKEqualizerCB - Radio

I 10 Volt Gas Electric Aluminum ChromeManual Electric12 Volt Aux Heater Washer/Dryer

BATHROOM

AC/DC Converter Rubber RoofHOLDING TANKS

Aqua Hot

Tub Shower

Invertor Hydro Hot Spot LightsGrey Water

Sink Toilet

Watts WebastoWaste Water

Air Hours

Porta Potti

Monitor Panel Power Roof FansFresh Water

Heat Strips

Hot Water Heater

Generator Outside Shower# LPGWafts TV Antenna# FuelTV Antenna w/Booster# House Batteries

OTHER MECHANICAL RECEIPTS Date work done/Part(s):Desc/ $:

ITIRES ABOVE AVERAGE AVERAGE BELOW AVERAGE

SCA File # (Required) Ins. Company Claim Rep Name Claim Rep Phone #

Loss Date

Claim # Policy/Member # Insured Name Insured Phone #

Loss Type

CONDITION Check either Sub-category (Seats/Paint/Engine/etc.) or Category (INT/EXT/MECH/TIRE) or write in Description and $ amount.IINTERIOR BELOW AVERAGEAVERAGEABOVE AVERAGE

EXTERIOR BELOW AVERAGEAVERAGEABOVE AVERAGEMECHANICAL BELOW AVERAGEAVERAGEABOVE AVERAGEENGINE New/ Rebuilt Well Maint Minor Wear Needs Minor Work Needs Major Work Desc/ $:

Rebuilt Engine Yes No Miles on Rebuilt Cost: $TRANS New/Rebuilt Well Maint Minor Wear Needs Minor Work Needs Major Work Desc/ $:

Rebuilt Trans yes No Miles on Rebuilt Cost: $SUSPENSION New/Rebuilt Well Maint Minoir Wear Needs Minor Work Needs Major Work Desc/ $:

Rebuilt Susp yes No Miles on Rebuilt Cost: $