New Online Assignment Form

Please fill out the assignment sheet below. When you are finished, please review your entries and click the submit button.
Upon submission, you will receive an email confirming your assignment.

COMPANY INFORMATION

Company Name

Dispatcher Name

Adjuster Name

Phone Number

Fax Number

Address1

Address2

City

State

Zip Code

Email Address

INSURED/CLAIMANT INFORMATION

Claim Number

Date of Loss

Insured Name

Claimant Name

Address1

Address2

City

State

Zip Code

Home or Cell Phone

Work Phone

VEHICLE/CLAIM INFORMATION

Make

Model

Year

Color

License Plate

VIN

Type of Claim

Deductible

Impact/Loss Description

Special Instructions

Is the Vehicle Drivable?

Vehicle Location

Location Phone