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Liability Claim Online Assignment

 

  • Please provide as much information about the claim as possible
  • Required fields are marked by the * symbol.
  • If you do not have the information for a required field, please enter "unknown"
  • Claim Details and Assignment Type
    * DOL(mm/dd/yyyy)
    * Claim #
    Policy #
    * Claim Type
    Auto Liability
    General Liability
    Workmans Comp
    Other
     
    * Description of Loss
    * Assignment Type 
    Limited Assignment
    Full Assignment
    * General Assignment Instructions 
    Special Instructions for Statements/Interviews (optional below) 
      Do Not Contact Interview Only Recorded Statement Written Statement Include Summary In-Person Phone
    Insured
    Claimant
    Witnesses
    Client Information/Reporting Address
    * Client Company Name
    * First Name
    * Last Name
    * Mailing Address
    Building/Suite
    * City
    * State
    * Zip
    * Phone #
    Fax #
    * E-Mail Address
    Insured Name and Contact Information:
    * Insured First Name
    Middle
    * Last Name
    Company Name
    Address 1
    Address 2
    City
    State
    Zip
    * Phone #
    Other Phone #
    Fax #
    Instructions/Other Information Regarding Insured
    Claimant Information - Primary
    * Claimant First Name
    Middle
    * Last Name
    Company Name
    Address 1
    Address 2
    City
    State
    Zip
    * Phone #
    Other Phone #
    Fax #
    Instructions/Other Information Regarding The Primary Claimant

     

    * Are There Additional Claimants and/or Other Parties Involved? Yes No