Property Assignment
YOUR COMPANY
Adjuster Name
*
First Name
Last Name
Company
*
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 Address
*
CLAIM
DOL
*
-
Month
-
Day
Year
Date
Insurance Carrier
Claim Number
*
Policy Number
Deductible
*
Please include decimal.
INSURED
Insured 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 Address
ASSIGNMENT
Loss Location (if different than insured address)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Location Contact (if other than insured)
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
Instructions
*
Estimate/Photographs
Reach an Agreed Cost of Repairs
Confirm Cause of Loss
Request Fire/Forensic Investigation Services
Photo Only
Other
Damage Description
*
CLAIMANT
If other than Insured.
Claimant 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
example@example.com
INFO & ATTACHMENTS
Please include Policy Declaration Page(s) and any relevant endorsements.
Other Special Instructions
How do you prefer we return assignments to you?
Email
Mail
Fax
Files
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