Required fields are marked with the
*
symbol.
If you do not have the information for a required field, please enter "unknown".
Claim Details and Assignment Type
DOL (mm/dd/yyyy)
*
Claim #
*
Policy #
*
Type of Property Involved
Residential
Commercial
Industrial
CAT Code
Description of Loss/Peril
*
General Assignment Instructions
*
Client Information / Reporting Address
Client Company Name
First Name
Last Name
Mailing Address
Buildling/Suite
City
State
Zip
Phone
Fax
Email
Instructions/Other Information Regarding Client
Insured Name & Contact Information
Insured First Name
Middle
Last Name
Company Name
Address 1
Address 2
City
State
Zip
Phone
Phone 2
Fax
Email
Limit
Deductable
Coinsurance
Forms
Coverage A
Coverage B
Coverage C
Coverage D
Other
Other Information Concerning Coverage
Instructions/Other Insured Information
Agent Information
Agent First Name
Middle
Last Name
Agency/Broker Company Name
Address 1
Address 2
City
State
Zip
Phone
Phone 2
Fax
Email
Instructions/Other Information Regarding Agent
Information On Other Parties
Please use the following section for identifying additional parties to the loss, such as eye-witnesses, police officers, attorneys, etc
(Not Required).
Additional Party #1
Claimant
Witness
Other - Explain below
First Name
Middle
Last Name
Company Name
Address 1
Address 2
City
State
Zip
Phone
Phone 2
Fax
Email
Additional Information/Special Insturctions
Confirm Assignment Receipt
*
Email
Phone
By 1st Report
Report Within
*
1-3 Days
3-7 Days
7-15 Days
15-30 Days
Final Comments
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