Clone of New Assignment Form-2_2_master

Secure Case Assignment Form

Please submit new Investigative Assignments through our encrypted Jotform portal below. All submissions are transmitted securely and are treated as strictly confidential.
ATTN: We have a new, updated Case Assignment form that allows for a much better user experience and auto-entries to make your job easier! The Classic form will be deprecated on 9/1/2026, however, in the meantime you can use either form for submitting your Case Assignments by clicking the appropriate button below until then. Thank you!
- Your Company
- Your Name
- Your Phone Number
- Your E-mail
- Your Address - Autofill
- Your Address - Other
- Assignment Date
  
  MonthDayYear
  Date
- Type of Claim
- Claim or Case #
- Date of Loss
  
  MonthDayYear
  Date
- Insured Name
- Insured Phone
- Insured Address - Autofill
- Insured Address - Other
- Please select all the Service Type(s) you are requesting:
  
  Other
- Budget days
- Budget Amount $
- Due Date
  
  MonthDayYear
  Date
- Objectives & Instructions
  This window can be expanded by grabbing bottom right corner
- Subject Name
- Date of Birth
  
  MonthDayYear
  Date
- Subject Phone
- Social Security #
- Subject Address - Autofill
- Subject Address - Other
- Driver License
- Driver License State
  
  Street Address
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- Race
- Ethnicity
- Gender
- Hair Color
- Height
- Weight (lbs.)
- Other Identifiers
- Alleged Injuries
- Subject Vehicles
- Attorney or Legal Representative
- Attorney or Legal Representative Phone
- Upload All Files
  
  Browse Files
  Accepts Multiple Files - 100 MB Max Cancelof
Thank you for this opportunity to be of service!

561.218.3313 ◆ 888.801.4255 ◆ Admin@KelleyAlliance.com
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Secure Case Assignment Form