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Diminished Value of Texas Eligibility Form

Please complete the fields below to the best of your ability
An asterisk (*) denotes required fields.

Your Information:
* First Name: 
   Last Name: 
* Email Address:   
* Phone Number:  

Your Vehicle Information:
* Year: 
* Make :  (Manufacturer)
* Model :  (Type)
* Mileage at time of accident :  
* Is this vehicle a lease: Yes  No 
* Type of Vehicle:
Car  Hatchback/Wagon  SUV  Truck  Minivan  Van  Other: 

Accident Information:
* Date Accident Occurred:  
* Were you at fault?:  Yes   No
Were there any injuries to you or your passengers? Yes   No
Would you like to discuss your injuries with an attorney at no charge? Yes   No
Insurance company of other party: 
Your insurance company (if applicable):  
Type of Insurance claim: 
Location of impact on vehicle  (if applicable):  
Location of Accident:

* Amount of Damages:  (U.S. Currency)

Repair Shop Information: (This information is not necessary in determining if you are eligible for diminished value.)
Name of Repair Shop: 
Shop street address:  
Shop City:
Shop State: 
Shop Zip Code: 

If there is any thing more you would like us to know?:

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