Assign Claim

ASSIGNMENT SUBMISSION FORM

Company:

Claims Examiner:

Phone:

Fax:

Email:

Address:

City:

State: Zip

Claim/Policy #:

Date of Loss:

Type of Loss:

INSURED

Name

Phone: Home

Work

Address:

City:

State: Zip

CLAIMANT

Name

Phone: Home

Work

Address:

City:

State: Zip

SPECIAL INSTRUCTIONS:

FILE ATTACHMENT: