Assign a Claim

Your Name
First Last
Company Name
Other Company
Date
Date Format: MM slash DD slash YYYY
Email
Phone
Your relationship to the claim?
What type of assignment?
Upload Files or Documents Here
Drop files here or
Insured Name
First Last
Address of Damaged Property
Street Address Address Line 2 City State ZIP Code
Insurance Company
Policy Number
Status of Claim
Request Internal
Specific Requests

“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.”