Assign a Claim

What State is Loss Located?(Required)

Date of Loss

Address of Loss(Required)

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

Insured Name(Required)

First Last

Additional Insured Name

First Last

Insured Email(Required)

Insured Phone(Required)

Name of Person Completing Form

First Last

Your Company Name

Your Phone

Your Email

Contractor Information

Company Name

Contractor Phone

Contractor 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

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