Assignment Form

Company Information Policy Information Insured Claimant Loss Information Assignment Info

Company Information

Date:
First Name:
Last Name:
Email Address:
Company Name:
Company Address:
City:
State:
Zip Code:
Phone Number:
Fax Number:

Policy Information

Policy Number:
Begin Effective Date:
End Effective Date:
Claim Number:
Date Of Loss:
Time Of Loss:

Insured Information

First Name:
Last Name:
Address:
City:
State:
Zip Code:
Residence Phone:
Person To Contact:
Business Phone:
Contact Phone:

Claimant Information

First Name:
Last Name:
Address:
City:
State:
Zip Code:
Residence Phone:
Person To Contact:
Business Phone:
Contact Phone:

Loss Information

Location Of Loss:
Description Of Loss:

Policy Information

Applicable Limites:
Deductable:
Policy Forms/Endorsements:

Full Assignment

Special Instructions:


Limited Assignment

Non Waiver
Coverage Investigation
Official Reports
Photos
Determine Cause And Origin
Prepare Scope / Estimate
Obtain Statements
ACV/RCV Evaluation
Diagram
Agreed Price
Investigate Subrogation
Disposal Of Salvage
Total Loss Evaluation CCC/ADP

Further Information:

Our company can even offer your adjusters training seminars to better understand
property, automotive and marine issues!

Multi Line Insurance Adjusters Serving Middle Tennessee

  Columbia   Nashville   Chattanooga
  417 W. 7th Street   718 Thompson Lane, Ste 108-188   2288 Gunbarrell Rd. Ste 154-115
  Columbia, TN 38401   Nashville, TN 37204   Chattanooga, TN 37421