Assign A Claim

Carrier Information

First Name *

Last Name *

Company Name *

Email *

Primary Phone # *

Secondary Phone #

Insured Information

Insured Details * Individual Business

First Name of Insured *

Last Name of Insured *

Insured Street Address *

Insured City *

Insured State *

Insured Zip Code *

Insured Email

Insured Primary Phone #

Insured Secondary Phone #

Business Name *

Business Address *

Business Address City *

State for Business Address *

Business Address Zip Code *

Is The Contact Person The Same As The Insured? * Yes No

Claim Contact Information

Contact Person First Name *

Last Name

Contact Email

Contact Primary Phone #

Contact Secondary Phone #

Claim Information

Claim Details * Full Assignment Limited Assignment Scope Only

Claim # *

Type of Loss *

Date of Loss * MM/dd/yyyy

Is the Loss Location The Same As The Insured Location *

Loss Location *

Loss Location City *

Loss Location State *

Loss Location Zip Code *

Description of Loss *

Assignment Instructions

Additional Instructions

Coverage Amount A $

Coverage Amount B $

Coverage Amount C $

Coverage Amount D $

Deductible $

Claimant Information

Individual
Business
None

Claimant Name First Name * Last Name

Claimant Business Name * Claimant Contact Person First Name Last Name

Claimant Address Street Address Claimant City Claimant State Claimant Zip Code Claimant Email Claimant Primary Phone # Claimant Secondary Phone #

Additional Claimant Information Yes No

Additional Claimant * Individual Business

Additional Claimant First Name *

Last Name

Additional Claimant Business Name * Additional Claimant Contact Person First Name Last Name

Additional Claimant Street Address Additional Claimant City Additional Claimant State Additional Claimant Zip Code Additional Claimant Email Additional Claimant Primary Phone # Number Additional Claimant Secondary Phone #

File Upload

Please provide us any relevant files for claim assignment

Carrier Information

Insured Information

Claim Contact Information

Claim Information

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