New Assignment Submission Assign A Claim - Form "*" indicates required fields Full Name* Full Name Company Name Address Phone*Email* Claim Number Date Of Loss MM slash DD slash YYYY Type of Loss Loss Location Upload documentMax. file size: 100 MB.Additional Comments Box Insured #1Full Name Full Name Address PhonePhone TypePhone TypeCellHomeWorkAlternate PhonePhone TypePhone TypeCellHomeWorkYour Email Represented by Attorney? Yes No If yes, Please provide the Information Below:Insured #2Full Name Full Name Address PhonePhone TypePhone TypeCellHomeWorkAlternate PhoneAlternate Phone TypeAlternate Phone TypeCellHomeWorkEmail Represented by Attorney? Yes No If yes, Please provide the Information Below:Claimant #1Full Name Full Name Address PhonePhone TypePhone TypeCellHomeWorkAlternate PhoneAlternate Phone TypeAlternate Phone TypeCellHomeWorkEmail Represented by Attorney? Yes No If yes, Please provide the Information Below:Claimant #2Full Name Full Name Address PhonePhone TypePhone TypeCellHomeWorkAlternate PhoneAlternate Phone TypeAlternate Phone TypeCellHomeWorkEmail Represented by Attorney? Yes No If yes, Please provide the Information Below:Assignment InformationFull Name Full Name Address PhonePhone TypePhone TypeCellHomeWorkAlternate PhoneAlternate Phone TypeAlternate Phone TypeCellHomeWorkYour Email Represented by Attorney? Yes No If yes, Please provide the Information Below:Claimant #3Type of AssignmentType of AssignmentCasualtyPropertyWorker'sCompensation OtherDescription of Loss Loss LocationLoss LocationSame as Insured OneSame as Insured TwoSame as Claimant OneSame as Claimant TwoSame as Claimant ThreeOtherAddress Injury or Damage Description:AssignmentOther InformationUpload File(s)Max. file size: 100 MB.PhoneThis field is for validation purposes and should be left unchanged.
