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Registration Form

Basic Info

Repair Facility Name*

Username*

Type Of Shop

If Repair Facility is affiliated with any group network, please enter name.

Contact Details

Contact Title*

Contact First Name*

Contact Last Name*

Email*

Phone Numbers

Ext.

Add Phone

Physical Location

Address*

Zip Code*

City*

State*

County

Mailing Address

Address*

Zip Code*

City*

State*

County

Repair Facility Details

Years In Business*

Square Footage Of Office*

Square Footage Of All Production*

Annual Gross Sales

Max Cars available to repair at one time*

Currently utilize CCC One or the CCC Portal

Enable Automatic Scheduling (allow end users to select their own appointment times)

Federal Tax ID*

Attach W9*

State Tax ID*

Office Hours

Monday

Closed

Tuesday

Closed

Wednesday

Closed

Thursday

Closed

Friday

Closed

Saturday

Closed

Sunday

Closed

Preferred Network Status (please update the below rates that you are willing to provide to Sedgwick customers)

	Posted Rates (Normal Rates)	Preferred Network status rate (Sedgwick Customer Rates)
Body*	$	$
Paint Materials*	$	$
Mechanical/Electrical*	$	$
Frame*	$	$
Body and Paint Labor*	$	$
Structural*	$	$
Aluminum Structure*	$	$

Will you guarantee your repairs for the lifetime of the vehicle to Sedgwick customers?

Are you willing to use a mobile application to assist in your workflow with Sedgwick?

Do you have any estimators that are willing to do paid field inspections?

Are you willing to provide a parts % discount for preferred status? (then enter %)*

Training and Certification

Select any applicable certifications your facility holds

Paint booth able to accommodate extended height vans?

Current I-Car Gold Class Shop

ASE Blue Seal Certification

Certified Welder(s) on Staff?

Able to handle Heavy Duty Vehicles?

Aluminum Repairs?

Able to handle Sprinter Vans?

Are any technicians certified to work on electric/hybrid vehicles?

Additional Equipment and Services

Do you have a 4 wheel computerized alignment system?

Do you have Unibody/Frame repair equipment capable of restoring a vehicle to manufacturer specs?

Do you have any of these additional services at your repair facility?

Select All

Additional Comments

Images

Image of the front of your repair facility*

Select image...

Internal picture of your lobby and internal shop*

Select image...

I understand the contract and accept the terms electronically

Full name of Authorized Signer*

RegistrationDate

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