Assignment Form
Claim Information
Insurance Company
*
Claim Number
*
Policy Number
*
Deductible amount
Claim For
Select
Insured
Claimant
Date of Loss
*
Type of Loss
*
Select Type
Collision
Commercial Property
Comprehensive
Liability / PD
Other
Residential Property
Sub Type
FIRE
HAIL
THEFT
FLOOD
VANDALISM
OTHER
Service Requested
Field Appraisal
Desk Review
Photos Only
ACV Only
Diminished Value
Scene Investigation
Subrogation Review
Umpire Services
Appraisal Clause
Other/Misc
Unit Type
*
Auto/Truck
Boat
Classic Vehicle
HazardAndConditionOnly
HazardAndConditionOnly (Renewal)
Heavy Equipment
Motorcycle
Off Road
Other
Property
RCTExterior
RCTExterior (Renewal)
RV/Trailer
Trailer
Insured Name
Adjuster Information
First name
*
Last name
*
Email Address
*
Phone Number
*
Owner Information
Business Name
First Name
Last Name
Email Address
Phone Number
FAX Number
Contact Name
Address
*
Postcode
*
City
*
State
*
Vehicle Location
Same as Above
Vehicle Location
Select
Repair Shop
Salvage/Tow Yard
With Owner
Workplace
Other
Location Name
Location Phone
Address
City
State
Postcode
Property Damage
Damage
Vehicle Information
VIN
Decode
Year
Make
Model
License Plate
Color
Mileage
Vehicle Damage
*
Instructions
*
Attach File :
Drop file here or click to upload
