Assignment Form

All claim assignments are submitted to our home office. Specific field claims office and field adjuster contact information will be confirmed based on loss location and type of assignment.

Please complete the following information. We will contact you and acknowledge receipt within 24 hours.

Insurance Company Information:

Insurance Company:

Address:

City, State, Zip:

Adjuster name:

Adjuster Phone #:

Adjuster E-mail Address:

Policy information

Company:

Coverages and Deductibles:

Type Of Policy:

Forms:

Claim Information:

Claim Number:

Date Of Loss:

Loss Type:

Description Of Loss:

Insured Contact Information:

Insured Name:

Loss Address:

City:

State:

Zip:

Residence Phone:

Cell Phone:

Business Phone:

Contact Name:

Contact Phone:

Mortgage:

Additional information to follow via fax:
YesNo
Comments:

Attachment: