Casualty Assignment Claim #* Policy # Date of Loss* Claim TypeSelect valueAuto LiabilityGeneral LiabilityMediationAppraisalUmpireOther Description of Loss/Peril General Assignment Instructions/Claim Info Assignment TypeSelect valueFull AdjustmentTask Report WithinSelect value1-3 Days4-7 Days8-10 Days11-14 Days15-21 Days22-30Other Confirm Assignment ViaSelect valueEmailPhone Insured Claimant Witness Carrier/Client Company Carrier/Client Mailing Address Street Address City State / Province / Region Postal / Zip Code Claim Rep Carrier/Client Email Carrier/Client Phone Carrier/Client Fax Named Insured* Insured Email Insured Phone* Instructions/Other Info Regarding Insured Insured Mailing Address* Street Address City State / Province / Region Postal / Zip Code Loss LocationSame as Mailing AddressDifferent Address Loss Location Address* Street Address City State / Province / Region Postal / Zip Code Claimant Name Claimant Email Claimant Phone Claimant Address Street Address City State / Province / Region Postal / Zip Code Upload a File 1 Upload a File 2 Upload a File 3 Upload a File 4 Upload a File 5 Upload a File 6 Upload a File 7 Upload a File 8 Upload a File 9 Upload a File 10 reCAPTCHASubmitReset
