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Field Assignment Form

Only the 5 fields marked with a red asterisk are required fields.

Date (mm/dd/yy):
Name: *
E-mail: *
Company: *
Company Address:
City: *
State / Province:
ZIP Code:  
Phone: *
Fax: 
Policy #:
Effective dates (mm/dd/yy):
  to  
Claim #:      
Date of Loss (mm/dd/yy):
Time of Loss: AM  PM

Insured
Name:
Address:
City:
State:
Zip Code:
Residence Phone:
Person to Contact:
Business Phone:
Contact Phone:


Facts
Location of Loss:
Description of Loss or Accident:


Policy Information
Bodily Injury: Property Damage: 
Combined Single Limit: Medical Payments: 
Comprehensive Deductible: Collision Deductible:
Other Deductibles:  
Loss Payee
(if none, so indicate)		  


Insured Vehicle (if Auto Loss)
Vehicle #:
Year:
Make:
Model:
Plate #:
VIN #:
Owner's Name:
Owner's Address:
State:
ZIP Code:
Owner's Phone:  
Driver's Name:
Driver's Address:
State:
ZIP Code:
Driver's Phone:
Relation to Insured:
Driver's License #:
Date of Birth (mm/dd/yy)
Describe Damage:
Repair Estimate:
Where can vehicle be seen?
When:


Claimant Property Damage
 
Description:
Other Vehicle or Property Insured? Yes No
Company or Agency Name:
Policy #:
Owner/Claimant:
Owner's Address:
State:
Driver's Name:
Check if Driver is same as Owner Yes No
Driver's Phone:
Describe Damage:
Estimate Amount:
Where can vehicle be seen:
More than one adverse vehicle? Yes No
(If yes, please include information under "Further Information or Instructions" below)

Injured Parties (Insured or Claimant)
 
#1 Name:
Address:
State:
Zip Code:
Phone:
Age:   
   Pedestrian    Insured Vehicle       Adverse Vehicle
Extent of Injury:
#2 Name:
Address:
State:
Zip Code:
Phone: Age:  
   Pedestrian    Insured Vehicle       Adverse Vehicle
Extent of Injury
Additional Injured Parties?  Yes        No
(If yes, please include information under "Further Information or Instructions" below)


Witnesses
 
#1 Name:
e
Further Information or Instructions:


Assignment Type
 
Recorded Statement
Scene Investigation
Photo Assignment
Canvas
Clinic Inspection
Other
Description of Services Needed:


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