Assign a Claim

What State is Loss Located?
Address of Loss
Insured Name
Additional Insured Name
Name of Person Completing Form
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    “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.”