First Last Address Phone Email CLAIM INFORMATION Insurance Carrier Name Filing Name* Insurance Carrier Contact Number & Fax Number* Claim Number* Insurance Carrier Name Filing Name* Assignment Type New AssignmentSupplement Claim Type PropertyAutoContentsCommercialProperty ATTACHMENTS 1-4 Accepted file types: jpg, gif, png, pdf, doc, zip. You may upload up to 4 files Assignment Submission Form Claim Type CasualtyPropertyAuto AppraisalsDiminished Value Auto AppraisalsSpecial Investigations and SurveillanceWorkers CompensationMediation AttendanceThird-Party AdministrationCatastrophe Services
