New Assignment Form-1_1

ATTN: This Classic form has been deprecated as of 9/1/2026. Please click on 'Modern' link below to Submit your Case Assignment and be sure to bookmark the address for future submissions. Feel free to Contact Us with any questions. Thank you!
New Assignment Form

Thank you for choosing Kelley Alliance for your claims & investigative support!

Your Information

(To Upload Files See Below)
Your Company
Your Name
Phone Number
Your E-mail
Your Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Claim Information
Assignment Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Type of Claim
Claim or Case #
Date of Loss
Insured
Insured's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Insured's Phone
Assignment
Service Request
Service Request
Service Request
Budget days
Due Date
Budget Amount $
Objectives & Instructions
This window can be expanded by grabbing bottom right corner
Subject Information

For ease of use, or for multiple Subjects, use the upload feature below
Subject
Date of Birth
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Social Security #
Driver License
Race
Hair Color
Attorney
Height
Weight
Gender
Other Identifiers
Alleged Injuries
Subject Vehicles
Upload All Files

Browse Files
Accepts Multiple Files - 100 MB Max Cancelof
Thank you for this opportunity to be of service!

561.218.3313 ◆ 888.801.4255 ◆ Admin@KelleyAlliance.com
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