Assign a Claim

What State is Loss Located?

State

Address of Loss

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

Insured Name

First Last

Additional Insured Name

First Last

Insured Phone

Insured Email

Name of Person Completing Form

First Last

Your Company Name

Your Email

Your Phone

Contractor Information

Company Name

Contractor Phone

Contractor Email

Date of Loss

Type of Loss

What type of assignment?

If Supplement Dollar Amount Paid/Notes

Please Choose One

Upload Files or Documents Here

Drop files here or

Max. file size: 100 MB.

Insurance Company

Policy Number

Claim Number

Status of Claim

Request Internal

Notes

“By submitting an electronic form to Coastal Claims Services, Inc. for a referral, there is no contractual relationship formed with Coastal Claims Services, Inc. Rather, by submitting this form, you are submitting an offer to enter into a contract with Coastal Claims Services, Inc., based on terms to be further negotiated between the parties. This form is provided to facilitate the formation of a contract, and is not in and of itself, a contract.”