Claim Assignment Form

Insurance Claim Assignment Form
To assign us a job electronically, fill out this form, and hit the Submit button at the bottom.

Even if you don't have all the information, feel free to get started now. Fill in information you do have, click the Submit button at the bottom of the form, and a Power Equipment Restoration LLC representative will contact you via phone or e-mail to fill in the blanks.
Reporting Information
Report To

YouOther
Full Name

First NameLast Name
Company
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Claim Information
Carrier Name
Claim Handler Phone

Area CodePhone Number
Claim Handler Email
example@example.com
Claim #
Date of Loss
Insured
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number

Area CodePhone Number
Fax Number

Area CodePhone Number
E-mail
Loss Location If Different

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Loss Information
Describe Loss
Scope of Service
Other Notes
Should be Empty:

Insurance Claim Assignment Form