Assign a Claim

What State is Loss Located?(Required)

Date of Loss(Required)

Address of Loss(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Policyholder Name(Required)

First Last

Additional Policyholder Name

First Last

Policyholder Email(Required)

Policyholder Phone(Required)

Name of Person Completing Form

First Last

Your Company Name

Your Phone

Your Email

Contractor Information

Company Name

Contractor Phone

Contractor Email

Referral Source if not Contractor

Source Email

Type of Loss(Required)

Brief Description of the loss/damage(Required)

What type of assignment?

If Supplement Dollar Amount Paid/Notes

Please Choose One

Insurance Company(Required)

Policy Number(Required)

Status of Claim(Required)

Claim Number

File Upload

Drop files here or

Max. file size: 256 MB.

Notes

Request Internal