Casualty Assignment
Claim #
Policy#
Date of Loss
Claim Type
Select
Auto Liability
General Liability
Mediation
Appraisal
Umpire
Other
Description of Loss/Peril
General Assignment Instructions / Claim Info
Assignment Type
-Select
Full Adjustment
Task
Report Within
-Select
1-3 Days
4-7 Days
8-10 days
11-14 days
15-21 days
22-30 days
Other
Confirm Assignment Receipt
Email
Phone
Special Instructions for Statements / Interviews
Insured
Do Not Contact
Interview Only
Recorded Statement
Written Statement
Include Summary
In Person
On Phone
Claimant
Do Not Contact
Interview Only
Recorded Statement
Written Statement
Include Summary
In Person
On Phone
Witness
Do Not Contact
Interview Only
Recorded Statement
Written Statement
Include Summary
In Person
On Phone
Carrier/Client Information / Reporting Address
Carrier/Client Company
Claim Rep
Carrier/Client Mailing Address
Carrier/Client Email
Carrier/Client Phone
Carrier/Client Fax
Insured Name and Contact Information
Named Insured
Insured Mailing Address
Loss Location
Insured Email
Insured Phone
Instructions / Other Info Regarding Insured
Claimant Information
Claimant Name
Claimant Address
Claimant Email
Claimant Phone
Additional Information
(Please include applicable loss notice, policy forms, etc...)
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