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 reCAPTCHAThe combined size of all files cannot exceed 24MB in TOTAL.After clicking Submit, please wait for the green, "Your Form Was Successfully Submitted" message to appear. If you do not see a confirmation message, your form may not have been submitted successfully and you should try again.If you do not receive an email acknowledgement from us within 24 hours, please email assignments@davisclaimsservice.com or call 888-328-4785 opt. 1.SubmitReset
