Casualty Assignment Form

*Required field.

Urgency:	Rush Routine
Location of Assignment:	other:
Type of Assignment:
Contact Information
First Name:
Last Name:
Company:
Address:
City:
State:
Zip:
Tel:
Fax:
Email:
Your Claim #:
Preferred Form of Reports / Communications:
Insured Information
Insured:
Insured Contact:
Insured's Address:
City:
State:
Zip:
Phone:
Fax:
Driver:
Defense Attorney:
Firm:
Address:
City:
State:
Zip:
Phone:
Fax:
Claimant Information
Claimant:
Claimant's Address:
City:
State:
Zip:
Phone:
Fax:
Claimant's Attorney:
Firm:
Address:
City:
State:
Zip:
Phone:
Fax:
Policy Information
Policy #:
Term:
Type:
Fire or Misc. Coverage:
Forms or Items Covered:
Loss Payable:
Witness Information
Name:
Address:
City:
State:
Zip:
Phone:
Loss Information
Loss Date:
Time:
Location:
Facts:
Other Witnesses:
Special Instructions / Comments:
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