Casualty Claim

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Claim Assignment - Casualty/Liability/Automobile Property Damage
Policy Number:
Claim Number:
Insurance Company Name:
Insurance Company Adjuster Contact Info:
Name:
Work Phone:
Fax Number:
e-Mail:
Named Insured
Name:
Home Phone:
Work Phone:
Email:
Best Time to call:
Claim Information:
Date of loss: Click Here
Location of loss:
Type of loss:
Describe how loss occurred and any resulting damage:
Claimant Information:
Claimant Name:
Claimant Address:
Contact Number:
e-Mail:

Claimant Attorney:
(if applicable)
Attorney Address:
Attorney Phone #:

Other Insurance:
Carrier Phone #:
Carrier Claim/Policy #:
Adjuster Name:
Persons Injured:
(if applicable)
Name/address:
Phone number:
Nature of injuries:
Cause of injuries:
Coverage information:
Form Limit Deductible
Coverage
Coverage
Coverage
Coverage
Other

Other Endorsements/Information Concerning Coverage
Select type of assignment:
Accident Locus Activity check Asset Check
Canvass Full Investigation Garaging
Household Interrogatories Locate
Obtain Documents PD Photos Police Report
Scarring Statements Surveillance
Other    
Comments and/or other information:

 

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