My Claim Connection Photo Assignment Form

New Assignment Request Form
Important! Please read!
1. Please provide us with as much information as possible to aide us in setting up a your new photo estimating appraisal assignment.
2. The mobile number provided must belong to a smart phone with the ability to download applications (i.e. from App Store / Google Play)
3. Once submitted, you will receive an acknowledgement in your e-mail with information regarding the details of the assignment.
Please click Get Started below to being providing assignment information.

Insurance Company Information
Company: *
Company Address required on first assignment:
Adjuster: *

First Name Last Name
E-mail: *
Phone Number: *

Area Code Phone Number
Extension:
Level of Service requested *

FULL Appraisal with Fraud Detection FULL Appraisal with NO Fraud Detection Other Service Pre Arranged with MCC
Photo Claim Information
Assignment Type: *
Type of Loss: *
Claim #: *
Policy Number:
Deductible: If left blank, we will use "Unknown" on estimate
Date of Loss: *

Month Day Year
Insured Information
Insured Name: *
Contact (If insured is a business):
Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
E-mail:
Mobile Phone Required for Photo App *

Area Code Phone Number
This inspection is for:

Insured Claimant

Damaged Unit Information
The Last 6 digits of the VIN: *
Year:
Make:
Model:
License:
Color:
Additional Information
Description of Loss:
Description of Damage: *
Special Instructions:
Appraisal Requirements (Word, PDF, Excel)
Below you can attach additional documentation you may like us to have.
Shop Estimate (PDF)
Additional documents may include images, Word and Excel documents, and/or .ZIP files.
Additional Documents
Below, you may print a copy for your records. You must hit submit to transmit this information (even after you print a copy).
Should be Empty:

New Assignment Request Form