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Wednesday September 08 2010


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Automobile Liability Assignment

***IMPORTANT NOTE: ***

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To submit an assignment online, please complete the following information. Required fields are marked with *.

CLIENT/INSURANCE COMPANY INFORMATION:

*Assigning Party Name:
*Company Name:
*Address:
*City:
*State:
*Zip:
*Phone:
*Fax:
*Email:
*Claim Number:
Policy Number:
*Date of Loss:
Automobile Liability Assignment:
*Insured Name:
*Address:
*City:
*State:
*Zip:
*Telephone Number:
*Insured Driver Name:
Address:
City:
State:
Zip:
*Telephone Number:
Injuries:

No

Yes
Represented:

No

Yes
Attorney Name:
Address:
City:
State:
Zip:
Telephone Number:
Insured Vehicle:
*Insured Vehicle Description:
Coverages:
Location of Loss:
*Address:
*City:
*State:
Zip:
Claimant Vehicle:
Claimant Vehicle Description:
Claimant Driver Name:
Address:
City:
State:
Zip:
Telephone Number:
Type of Claim:

PD

BI
Represented:

No

Yes
Attorney Name:
Address:
City:
State:
Zip:
Telephone Number:
BI Claimant Name:
Address:
City:
State:
Zip:
Telephone Number:
Injuries:

No

Yes
Represented:

No

Yes
Attorney Name:
Address:
City:
State:
Zip:
Telephone Number:
Witness Name, Addresses, & Phone Numbers:
Facts & Handling Instructions:
Additional necessary
information is being:

Faxed

E-Mailed

Sent By Mail

Have Adjuster Contact Examiner

 





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