New Casualty Claim Assignment
New Casualty Claim Assignment
Required fields are marked by the * symbol
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Assigning Company Name
*
We are to Report to:
First Name
*
Last Name
*
Phone #
*
E-Mail
*
Date of Loss
*
Claim/File Reference#
*
Policy #
Mailing Address
Building/Suite
City
State
Zip
Claim Type
*
Auto Liability
General Liability
Other
Other
Description of Loss
*
Assignment Instructions
*
Special Instructions for Statements/Interviews (optional below)
Insured
Interview Only
Recorded Statement
Written Statement
Include Summary
In Person
Phone
Claimant
Interview Only
Recorded Statement
Written Statement
Include Summary
In Person
Phone
Witnesses
Interview Only
Recorded Statement
Written Statement
Include Summary
In Person
Phone
Insured Name
*
Mailing Address
Email Address
City
State
Zip
Phone #
Other Phone #
Instructions/Other Information Regarding Insured
Claimant Information - Primary
Please use the following section for identifying additional parties to the loss, such as eye-witnesses, police officers, attorneys, etc. (Not Required)
Claimant Name
Address
City
State
Zip
Phone #
Other Phone #
Email Address
Instructions/Other Information Regarding the Primary Claimant
Are there additional claimants and/or other parties involved?
*
Yes
No
If yes, please add information
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