New Assignment - Professional Claims Representatives

1CLIENT INFORMATION

2INSURED INFORMATION

3CLAIMANT INFORMATION

4COVERAGE INFORMATION

5LOSS INFORMATION

Company:

Adjuster Email:(Required)

Address:

Phone

City, State, & Zip:

Extension:

Adjuster Name:

Fax:

Company:

Phone:

Address:

Phone:

City, State, & Zip:

Phone:

Claimant:

Phone:

Address:

Phone:

City, State, & Zip:

Phone:

Has liability been accepted or discussed?

Coverage issues related to claim? Please list any endorsements or class codes.

Has the claimant submitted their claim to their insurance carrier?

Is an ITEL sample needed?

Is a R/S needed? Claimant, insured, or witness?

Claim No:

Policy No:

Type of Policy:

Effective Date:

Coverage Amounts

Deductible:

Lien Holder:

Date of Loss:

Loss Location:

Description of Loss:

Special Instructions:

select

Full Adjustment

Agreed Appraisal

File Attachment 1:

Max. file size: 1 GB.

File Attachment 2:

Max. file size: 1 GB.

File Attachment 3:

Max. file size: 1 GB.

File Attachment 4:

Max. file size: 1 GB.

File Attachment 5:

Max. file size: 1 GB.

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