Property Claim

    Date:

    Name:

    E-Mail:

    Company:

    Company
    Address:

    State:

 

ZIP/Postal Code:

    Phone:

Fax:

    Policy # :

Claim #:

    Effective
    Dates:

 


TO

 
    Date of
    Loss: 

    Time of
    Loss:

  

A.M.

P.M.

                    ___________________________________________________

Insured

    Name:

    Address:

    State:

ZIP Code:

    Phone:

Work #:

    Person to
    Contact:

    Contacts
    Phone:

_________________________________________________

Facts

    Loss
    Location:



    Description of Loss:

    ___________________________________________

Policy Information

    Applicable
    Limits:


Deductible:


Policy Forms / Endorsements:  

       _______________________________________________

Full Assignment

    Special Instructions:

 

Limited Assignment

      Non Waiver          Coverage Investigation

      Official Reports  

      Photos         Determine Cause & Origin

      Prepare / Scope Estimate          Obtain Statements

      Obtain Statements From

      ACV / RCV Evaluation         Diagram      

      Agreed Price         Investigate Subrogation

      Dispose of Salvage         Other 

    Further Information or Instructions: