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SUBMIT ASSIGNMENT
NEW ASSIGNMENT FORM
Contact (First & Last Name)
Email
Company Name
Phone
ASSIGNMENT DETAILS:
Type of Assignment
Select One
Date of Loss
Date Reported
Insured (First & Last Name)
Carrier Name
Loss Type
Select One
Claim No.
Other Reference No.
Loss Location or Risk Address (include City/State/Zip)
PERSON OF INTEREST DETAILS:
Person of Interest (First & Last Name)
Relation
Select One
Is Person of Interest Represented?
Public Adjuster
Attorney
Date of Birth
Gender
Select One
Injuries
Home Address
City / State / Zip
Additional Information
Upload File
Upload supported file (Max 15MB)
Upload File
Upload supported file (Max 15MB)
Upload File
Upload supported file (Max 15MB)
Service Requested:
In-person Recorded Statement
Phone Statement
Video Statement
Neighborhood Canvass
Scene/Site Investigation
License Plate Reader Data Retrieval (LPR)
Attempt to Locate
(check all that apply)
Witness Statement
Document Retreival or Delivery
Comprehensive Background Research (includes social media)
Surveillance
Notary Services
Drone Services
Other
Thanks for the assignment!
We look forward to working with you.
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