Catastrophe Assignment Form

Location of Adjuster Assignment

City(Required)

State(Required)

Country(Required)

Submitted By

Name(Required)

First Last

Contact information

Phone Number(Required)

Email(Required)

Cell Phone Number

Fax Number

Company

Company Name(Required)

Branch/Office Number

Address

Address(Required)

Street Address Address Line 2 City State ZIP Code

Report to

Report to someone different from above?(Required)

Name(Required)

First Last

Contact information

Phone Number(Required)

Email(Required)

Cell Phone Number

Fax Number

Loss Information

Customer Claim Number

Brief Description of loss(Required)

Date of loss(Required)

Location of Loss

Insured Information

Insured Person/Company(Required)

Name

Insured First Name Insured Last Name

Insured Address

Street Address Address Line 2 City State ZIP Code

Insured Home Phone Number

Insured Cell Phone Number

Insured Work Number

Insured Email

File

Max. file size: 100 MB.

Actions(s) to take / Special Instructions