Casualty Assignment Form

Location Adjuster Assignment

City*

State/Province.*

Country*

Submitted by

Name*

First Last

Contact Information

Phone Number*

Email*

Cell Phone

Fax number

Company

Company Name*

Branch / Office number

Address*

Street Address Address Line 2 City State ZIP Code

Report to

Report to someone different from above?*

Name

First Last

Phone number

Cell Phone

Fax number

Policy Details

Policy number

Policy Effective Date

Loss Information

Customer Claim Number

Brief Description of Loss*

Date of loss*

Location of loss

Were Police Called?*

Name of Police Deparment

Was Fire Dept. Called?*

Insured Information

Insured Person / Company*

Name

Insured First Name Insured Last Name

Insured Address

Street Address Address Line 2 City State ZIP Code

Insured Home Phone Number

Insured Email

Insured Cellphone number

Insured Work Number

Injured Party Name

Injured Party Firts Injured Party Last

Description of Injury(ies)

Claimant Information

Description of Injury(ies)

Injured Party Name

Injured Party Firts Injured Party Last

Injured Party Phone number

Injured Party Email

Witness Information

Name

Witness First Name Witness Last Name

Address

Witness Street Address Witness Address Line 2 Witness City Witness State Witness Zip Code

Witness Phone Number

Witness Email Address

Witness Cell Phone Number

Witness Work Phone Number

Attach File to this assigment

Max. file size: 100 MB.

Action(s) to take / Special Instructions