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Online Assignment Form

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1Step 1

2Step 2

3Step 3

4Step 4

Loss Location
Loss Location Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Loss Location Notes
Contact Information
Contact #1
Contact #1 (other)
Full Name
First Last
Home Phone
Work Phone
Cell Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Contact information status
- Address verified as valid
- Returned mail at address
- Party not responding to phone calls
- Party speaks foreign language:
Specify Foreign language (Contact #1)
Attorney / Public Adjuster
Add another Contact
- Yes
Contact Information #2
Contact #2
Contact #2 (other)
Full Name
First Last
Home Phone
Work Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Contact information status
- Address verified as valid
- Returned mail at address
- Party not responding to phone calls
- Party speaks foreign language:
Specify Foreign language (Contact #2)
Attorney / Public Adjuster
Add another Contact
- Yes
Contact Information #3
Contact #3
Contact #3 (other)
Full Name
First Last
Home Phone
Work Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Contact information status
- Address verified as valid
- Returned mail at address
- Party not responding to phone calls
- Party speaks foreign language:
Specify Foreign language (Contact #3)
Attorney / Public Adjuster
Vehicle #1
Vehicle #1 Other
Year
Make
Model
Color
License#
VIN#
Location
Add another vehicle?
- Yes
Vehicle #2
Vehicle #2 Other
Year
Make
Model
Color
License#
VIN#
Location
Add another vehicle?
- Yes
Vehicle #3
Vehicle #3 Other
Year
Make
Model
Color
License#
VIN#
Location

Abestos
Assault
Auto
Biohazard
Bodily Injury
Collapse
Discrimination/Violence
Dog Bite
Electrical
Explosion
Fatality
Fence
Fire
Flooring/Carpeting
Frame Damage
Hail
Landscaping
Lead
Lightening
Mold
Roof
Sewage
Slip and Fall
Smoke
Snow
Spa/Pool/Sauna
Structural Damage
Theft
Tractor/Trailer
Tree Roots
Vandalism
Vegetation
Vermin
Water
Wind
Other

Online Assignment Form

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