Assignment Form
CLAIM NUMBER
*
DATE OF LOSS
-
Month
-
Day
Year
Date
POLICY NUMBER
ADJUSTER'S NAME
TYPE OF LOSS
DEDUCTIBLE
VEHICLE OWNER'S INFORMATION
NAME
ADDRESS
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
PHONE
Please enter a valid phone number.
Format: (000) 000-0000.
INSURED INFORMATION
NAME
ADDRESS
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
PHONE
Please enter a valid phone number.
Format: (000) 000-0000.
CLIENT INFORMATION
NAME
ADDRESS
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
PHONE
Please enter a valid phone number.
Format: (000) 000-0000.
VEHICLE / LOSS UNIT INFORMATION
YEAR
Please Select
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
MAKE
MODEL
PLATE NUMBER
VIN #
ADDITIONAL EQUIPMENT / VEHICLE INFORMATION
LOCATION OF VEHICLE / LOSS UNIT
SERVICES / SPECIAL INSTRUCTIONS / ADDITIONAL INFORMATION
NOTIFY ASAP IF TOTAL LOSS?
YES
NO
AGREED PRICE APPRAISAL?
YES
NO
ACTUAL CASH VALUE?
YES
NO
POLICE REPORT?
YES
NO
RECORDED STATEMENT?
YES
NO
PHOTOCOPY OF TITLE?
YES
NO
OTHER ACTIVITY / INFORMATION
BRIEFLY DESCRIBE
ADDITIONAL CLAIM ACTIVITY
ASSIGNED BY:
DATE ASSIGNED:
-
Month
-
Day
Year
Date
PHOTOS
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