Auto Assignment Form
YOUR COMPANY
Adjuster Name
*
First Name
Last Name
Company
*
Billing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
FAX Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
CLAIM
DOL
*
-
Month
-
Day
Year
Date (Enter Today's Date if Unkown)
Insurance Carrier
Claim Number
*
Policy Number
Deductible
*
Please include decimal.
INSURED
Insured Name
*
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
FAX Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
INSURED VEHICLE
Year
Make
Model
VIN
Damage Description
Vehicle Location
*
INSURED VEHICLE ASSIGNMENT
IV Assignment Tasks
*
Estimate/Photographs
Complete Condition Report
Obtain Actual Cash Value Report
Obtain Salvage Bids
Settle Total Loss
Settle Salvage
Desk Review
Photo Only
Low Impact Photographs
Other
Is the vehicle a total loss?
Yes
No
Unknown
Do you want us to move salvage?
Yes
No
If yes, where to? (Name)
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
CLAIMANT
Claimant Name
First Name
Last Name
If Commercial, Business Name
Name
First Name
Full Name or Business
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
FAX Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
CLAIMANT VEHICLE
Year
Make
Model
Vehicle Location
Damage Description
CLAIMANT VEHICLE ASSIGNMENT
CV Assignment Tasks
Estimate/Photographs
Complete Condition Report
Obtain Actual Cash Value Report
Obtain Salvage Bids
Photo Only
Low Impact Photographs
Other
Is the vehicle a total loss?
Yes
No
Unknown
Do you want us to move the salvage?
Yes
No
If yes, where to? (Name)
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
INFO & ATTACHMENTS
Other Special Instructions
How do you prefer we return assignments to you?
Email
Mail
Fax
Files
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