Assign A Claim

Client

Your Name* (Required)

Company Name* (Required)

Address

City

US State

Country

Zip Code

Phone* (Required)

Reporting Preference

Email* (Required)

Confirm Email* (Important to receive assignment receipt)

Claim Number

Date of Loss

Policy Number

Policy Effective Dates


to

Insured #1

Insured Name

Address

City

US State

Country

Zip Code

Phone

Type

Alternate Phone

Type

Email

Represented by attorney?

If yes, please provide information below

Insured #2

Insured Name

Address

City

US State

Country

Zip Code

Phone

Type

Alternate Phone

Type

Email

Represented by attorney?

If yes, please provide information below

Claimant #1

Claimant Name

Address

City

US State

Country

Zip Code

Phone

Type

Alternate Phone

Type

Email

Represented by attorney?

If yes, please provide information below

Claimant #2

Claimant Name

Address

City

US State

Country

Zip Code

Phone

Type

Alternate Phone

Type

Email

Represented by attorney?

If yes, please provide information below

Claimant #3

Claimant Name

Address

City

US State

Country

Zip Code

Phone

Type

Alternate Phone

Type

Email

Represented by attorney?

If yes, please provide information below

Assignment Information

Type of Assignment

Description of Loss

Loss Location

Loss Location Address (if different)

City

US State

Country

Zip Code

Injury or Damage Description

Assignment

Other Information

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