62 Baldwin Street • West Springfield, MA 01089-3706 • (413) 733-7134 Fax: (413) 732-7610 • Andre@WesternMassCollision.com
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Name*: Address*: City*, State*, Zip*: Please be sure to list at least one phone number so we can contact you - Home, Work or Cell Home Phone: Work Phone: Cell Phone: Email: Insurance Company: Date of Loss (D.O.L.): Claim No.: Are You the Insured or Claimant?: Insured Claimant Not an insurance claim Year: Make: Model: Tow: Yes No Vehicle Location: Tow Charges: Comments and Questions: * required fields