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 Email
Insured Phone
Name of Person Completing Form
First Last
Your Company Name
Your Email
Your Phone
Contractor Information
Company Name
Contractor Email
Contractor Phone
What type of assignment?
Type of Loss
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.”