Investigation Assignment
Origin & Cause / Forensic Investigations from IC Specialty Services
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
Insurer
Claim Number
*
Policy Number
INSURED
Insured Name
*
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Location Loss (if different from above)
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
Alternate Contact:
Alternate Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Damage Description
CLAIMANT
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
Damage Description
ASSIGNMENT INSTRUCTIONS
Type of Assignment
Residential O&C
Commercial O&C
Explosion Investigation
Forensic Exam/Water Loss
Case Review/Consultation
Expert Witness Testimony
Is a Property Adjuster needed?
Yes
No
Other Involved Parties
Other Special Instructions
Files
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