North America's Only Independent Crash Data Laboratory.

Secure Storage Program

VIN

Vehicle Location - Current

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Manufacture

Year

Model

Vehicle Condition

Safety System Status

Black Box Condition

Other Damage Description

Case, Claim, ID or Reference #

Crash Date

YYYY

Is the Black Box Supported?

Verified by the Search Tool, Bosch software, or our Service Team.

Phone

(###)

###

####

Authorization

I am the owner or lessee, or am now the appointed administrator, or personal representative of the estate, or legal representative of such an owner, or a law enforcement officer with the appropriate documentation, of the described vehicle that may have stored electronic data on the said vehicle’s components. I acknowledge my rights under the "Driver Privacy Act of 2015," and I am hereby authorizing Black Box Recovery to recover and/or store the components from the said vehicle.

Authorization Signature

Submit YOUR electronic signature.

First Name

Last Name

Verification Signature

Verify YOUR electronic signature.

First Name

Last Name

Your Title

Other Title

If Title not listed please describe.

Storage Length (Month/s)

Select # of month/s to store Black Box (+ $50/Mo.)

Affiliate Code Only

Enter Your Affiliate Code

Secure Storage Program

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(405) 277-7090
service@blackboxrecovery.com

820 W Danforth Unit 305 Edmond, OK 73003