Assign a Property Claim

   
Date (mm/dd/yy):
Name:*
E-mail:*
Company:*
Company Address:
City:*
State / Province:
ZIP Code:  
Phone:*
Fax: 
Policy #:
Effective dates (mm/dd/yy):
  to  
Claim #:
     
Date of Loss (mm/dd/yy):
Time of Loss:
AM  PM

Insured
Name:
Address:
City:
State:
Zip Code:
Residence Phone:
Person to Contact:
Business Phone:
Contact Phone:

Claimant
Name:
Address:
City:
State:
Zip Code:
Residence Phone:
Person to Contact:
Business Phone:
Contact Phone:


Facts
Location of Loss:
Description of Loss:


Policy Information
Applicable Limits: 
Deductible: 
 
Policy Forms / Endorsements: 
 
     
     

Full Assignment

Special Instructions:
Limited Assignment
 
Non Waiver
 
 
 
Coverage Investigation
 
Official Reports  
 
Photos
 
 
 
Determine Cause and Origin
 
Prepare Scope / Estimate
 
Obtain Statements from
 
ACV / RCV Evaluation
 
Diagram
 
 
 
Agreed Price
 
 
 
Investigate Subrogation
Dipose of Salvage
 
Other  
   
Further Information or Instructions: