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Claim Details and Assignment Type
DOL
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Claim #
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Policy #
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Claim Type & Description
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Auto Liability
General Liability
Product Liability
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Description of loss
Assignment Type & Instructions
Assignment Type
Limited Assignment
Full Assignment
General Assignment Instructions
Special Instructions for Statements/Interviews (optional below)
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Recorded Statement
Written Statement
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In-Person
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Insured
Claimant
Witnesses
Client Information / Reporting Address
Client Company Name
First Name
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Mailing Address
Buildling/Suite
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Instructions/Other Information Regarding Client
Insured Name & Contact Information
Insured First Name
Middle
Last Name
Company Name
Address 1
Address 2
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State
Zip
Phone
Phone 2
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Instructions/Other Information Regarding Insured
Claimant Information - Primary
Claimant First Name
Middle
Last Name
Company Name
Address 1
Address 2
City
State
Zip
Phone
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Are There Additional Claimants and/or Other Parties Involved?
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Instructions/Other Information Regarding Claimant
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