Liability Assignment Form
YOUR COMPANY
Adjuster Name
*
First Name
Last Name
Company
*
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
Insurance Carrier
Claim Number
*
Policy Number
Loss Location
Accident Description
INSURED
Insured Name
*
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Cell Number
Please enter a valid phone number.
Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Fax Number
Email Address
ADVERSE PARTY
Adverse Party Name
Mailing 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
example@example.com
WITNESS
Witness Name
Witness Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
INVESTIGATION & SPECIAL HANDLING INSTRUCTIONS
Do you want us to take a recorded statement?
Yes
No
If so, who?
Scene investigation?
Yes
No
Obtain police report?
Yes
No
Police Department
Case Number
Are O&C Services needed?
Yes
No
Auto Appraisal?
Yes
No
Appraisal Vehicle(s)
Insured
Claimant
Vehicle Location
Appraisal 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
Total loss instructions
Do you want us to move salvage?
Yes
No
If so, 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.
Other Special Instructions
INFO & ATTACHMENTS
How do you prefer we return assignments to you?
Email
Mail
Fax
Files
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