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New Assignment for Integrated Claim Solutions
Your Contact Information
First Name
Last Name
Company
Address
(Line 1)
(Line 2)
City
State
AA
AB
AE
AK
AL
AP
AR
AZ
BC
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MI
MN
MO
MS
MT
NB
NC
ND
NE
NF
NH
NJ
NM
NS
NT
NU
NV
NY
OH
OK
ON
OR
PA
PE
PR
QC
RI
SC
SD
SK
TN
TX
UT
VA
VT
WA
WI
WV
WY
YT
ZIP
Phone:
eMail:
New Assignment Information
Your Claim #:
Assignment Instructions:
Characters left:
Insured's Information
Policy #:
Phone #:
Alternate Phone #:
Company:
First Name:
Last Name:
Street Address:
Address 2:
City:
State:
AA
AB
AE
AK
AL
AP
AR
AZ
BC
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MI
MN
MO
MS
MT
NB
NC
ND
NE
NF
NH
NJ
NM
NS
NT
NU
NV
NY
OH
OK
ON
OR
PA
PE
PR
QC
RI
SC
SD
SK
TN
TX
UT
VA
VT
WA
WI
WV
WY
YT
Zip:
Mortgagee:
Loss Location
Street Address:
Address 2:
City:
State:
AA
AB
AE
AK
AL
AP
AR
AZ
BC
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MI
MN
MO
MS
MT
NB
NC
ND
NE
NF
NH
NJ
NM
NS
NT
NU
NV
NY
OH
OK
ON
OR
PA
PE
PR
QC
RI
SC
SD
SK
TN
TX
UT
VA
VT
WA
WI
WV
WY
YT
Zip:
Claimant Information
(if applicable)
First Name:
Last Name:
Phone:
Street Address:
Address 2:
City:
State:
AA
AB
AE
AK
AL
AP
AR
AZ
BC
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MI
MN
MO
MS
MT
NB
NC
ND
NE
NF
NH
NJ
NM
NS
NT
NU
NV
NY
OH
OK
ON
OR
PA
PE
PR
QC
RI
SC
SD
SK
TN
TX
UT
VA
VT
WA
WI
WV
WY
YT
Zip:
Agent Information
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Hide
First Name:
Last Name:
Company:
Office Phone:
Cell Phone:
Street Address:
Address 2:
City:
State:
AA
AB
AE
AK
AL
AP
AR
AZ
BC
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MI
MN
MO
MS
MT
NB
NC
ND
NE
NF
NH
NJ
NM
NS
NT
NU
NV
NY
OH
OK
ON
OR
PA
PE
PR
QC
RI
SC
SD
SK
TN
TX
UT
VA
VT
WA
WI
WV
WY
YT
Zip:
Country:
Loss Information
Date of Loss:
Type of Loss:
Water
Wind
Fire
Theft
Hail
Lightning
Collision
Comprehensive
Property Damage
Liability
Bodily Injury
Demand Review
Vandalism
Falling Objects
Dog Bite
Fatality
Slip & Fall
Demand and Bill Review
Construction Defect
SIU Investigation
Hurricane
Subrogation Claim
EUO
Re-Inspection
Appraisal
Coverage Analysis
PIP
UM
Estimate Review
Desk Review
Inspection
Unit:
Residential Property
Commercial Property
Homeowner's Liability
Commercial Liability
Personal Auto
Commercial Auto
Auto Liability
Bodily Injury
Demand and Bill Review
Auto Appraisal
Mediation
Demand Review
Falling Objects
Appraisal
Construction Defect
Fatality
Marine
General Liability
Garage Policy
Sign Affadavit
Sign Release of all Claims
Construction Defect
Hand Deliver Letters
SIU Investigation
Collision with pedestrian-bicycle
Collision with pedestrian
Jewelry Appraisal
Subrogation Claim
Collision with motorcyclist
EUO
Re-Inspection
Mobile Home
Inspection
Business Income
Garaging Investigation
Coverage
Create Values
Residential Liability
Coverage Analysis
Additional handling required
Appraisal
PIP
Coverage Analysis
Obtain PR
Affidavit
Rebuild
Pick Up Check
BI
UM
Workers' Compensation
Desk Review
Type of Adjustment:
Limited
Full
Loss Description:
Characters left:
VIN #:
Deductible:
Wind Deductible:
Coverage A
Coverage B
Coverage C
Coverage D
Endorsements:
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