Casualty Assignment (AL, GL, WC, etc.)
Client Information/Reporting Address
Please provide as much information about the claim as possible Required fields are marked by the symbol If you do not have the information for a required field, please enter "unknown"
Client Company Name
First Name
Last Name
Mailing Address
Building/Suite
City
State
Zip
Phone
Ext
Fax
Email Address
Claim Details and Assignment Type
DOL(mm/dd/yyyy)
Claim/file #
Policy #
CAT Code
Description of Loss/Peril
Please enter the scope of your assignment
Site Investigation
Interview Insured
R/S Insured
R/S Employee/ Witness
R/S Claimant
R/S Claimant - Non Injury Statement
Determine Liability
Determine Damages
Call Back w/Figures
Determine Cause And Origin
Photos/Diagrams
Determine Injuries
Settlement Authority
Subrogation Investigation
Call Client A.S.A.P.
Call Client From Scene
Interview Police Officer
Obtain Police Report
Others - See Comments
Additional Instructions and Comments
Please select the type of Assignment
Full Assignment
Partial Assignment
Appraisal only
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