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.”