New Assignment Request Form

IMPORTANT - PLEASE READ.

-Please provide us with as much information as possible to aide us in setting up a new appraisal for you.

-Please be sure to provide as least one good contact number for the vehicle owner.

-Once submitted, you will receive an acknowledgement in your e-mail with information regarding the appraisal for your claim.

-If submitted before 3 PM, and no acknowledgement is received by 5 PM, please call our office to confirm we received the request.

Company*:

Adjuster*:

E-mail*:

Phone*:

Extension:

Fax:

Claim Info

Assignment Type*:

Type of Loss:

Claim #*:

Policy #:

Deductible:

Date of Loss:

Claimant Vehicle?

Insured Info

Insured:

Address:

City:

State:

Zip Code:

Home Phone:

Work Phone:

Mobile Phone:

Other Phone:

Claimant Info

Claimant:

Address:

City:

State:

Zip Code:

Home Phone:

Work Phone:

Mobile Phone:

Other Phone:

Damaged Unit Information

VIN:

Year:

Make:

Model:

License Plate:

Color:

Unit Location:

With the Owner

At Another Location (i.e. Body Shop, Tow Yard, Workplace)

Location Name:

Location Address:

Location City:

State:

Location Zip:

Location Contact:

Location Phone:

Description of Loss:

Description of Damage:

Special Instructions:

Click to Save: Company Name

Adjuster's Name

Adjuster's E-mail

Adjuster's Phone