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New Assignment for VAIS - Dakota Claims Service of Aberdeen & Huron
Your Contact Information
First Name
Last Name
Company
Address (Line 1)
(Line 2)
City
State	AAABAEAKALAPARAZBCCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMBMDMEMIMNMOMSMTNBNCNDNENFNHNJNMNSNTNUNVNYOHOKONORPAPEPRQCRISCSDSKTNTXUTVAVTWAWIWVWYYT
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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:	AAABAEAKALAPARAZBCCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMBMDMEMIMNMOMSMTNBNCNDNENFNHNJNMNSNTNUNVNYOHOKONORPAPEPRQCRISCSDSKTNTXUTVAVTWAWIWVWYYT
Zip:
Mortgagee:
Loss Location
Street Address:
Address 2:
City:
State:	AAABAEAKALAPARAZBCCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMBMDMEMIMNMOMSMTNBNCNDNENFNHNJNMNSNTNUNVNYOHOKONORPAPEPRQCRISCSDSKTNTXUTVAVTWAWIWVWYYT
Zip:
Claimant Information (if applicable)
First Name:
Last Name:
Phone:
Street Address:
Address 2:
City:
State:	AAABAEAKALAPARAZBCCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMBMDMEMIMNMOMSMTNBNCNDNENFNHNJNMNSNTNUNVNYOHOKONORPAPEPRQCRISCSDSKTNTXUTVAVTWAWIWVWYYT
Zip:
Agent Information Show | Hide
First Name:
Last Name:
Company:
Office Phone:
Cell Phone:
Street Address:
Address 2:
City:
State:	AAABAEAKALAPARAZBCCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMBMDMEMIMNMOMSMTNBNCNDNENFNHNJNMNSNTNUNVNYOHOKONORPAPEPRQCRISCSDSKTNTXUTVAVTWAWIWVWYYT
Zip:
Country:
Loss Information
Date of Loss:
Type of Loss:	WaterWindFireHailCollision Collision/ Property DamageComprehensiveProperty Damage Animal TrespassAppraisal Assist - Limited Assignment Bodily Injury / Med pay Cattle Trespass Bodily Injury/ Property Damage CargoCollapseErrors & Ommissions Fire to Farm Tractor Freezing Inspection Investigation Lease Turn In - Inspection, photos & forms Limited Assignment Limited Assist Liability Low Impact Market Survey Misapplication of Chemical Photographs Power Failure Re-inspection Slip and Fall Scene Investigation Spray / Misapplication Statement from Claimant Subrogation Investigation Theft Unknown Vandalism Vehicle Fire Work Comp. Investigation Accidental Physical Damages Animal Mortality Damage to Baler Damage to Building by Vehicle Business Income Business Interruption Damage to Carpet or Wood Flooring Collapse Due to Heavy Rains Damage due to Collapse of the Structre Combine Ingested Rock Damage to Combine Damage to BoatDamage to Tractor Damage by Rodents Diesel Fuel Leak Damage by Rainstorm Damage by Tree or Branch Damage by Dry Rot Electrical Surge Damage by Earthquake Damage by Explosion Damage by Hail Food Spoilage LossDamage by Fire Floor Buckeling Damage by Flood Freezing / Thawing Freeze/ Due to Failure of Power Freezing/ Water Damage Fuel Spill Furnace Puff Back GFI Outlet Failure Damage by Extreme Heat Damage by Ice/Snow Damage by Hurricane Damage to Property of Others Damage by Lightning Liabilty Investigation BPP - Malfunction Medical Expense Damage by Mischief Damage by MoldOther - Paint Spill on Carpet Other - Accident Causing Damage to HomeDamage due to Other First Party PerilPower OutagePower Surge Property Re-Inspection Rain - Water Damage Damage by Sewer BackupDamage by Smoke Damage from Snow Storm Damage by Soot Sump Pump Failure Tornado Damage to Tracor/ MowerVandalism Water Damage / Foreclosure Damage by Vehicle Water Backup Wind Driven Rain Work Comp Building Damage due to temperature changes.Employee DishonestyUnderground Service Line ClaimWind/HailWind/Water
Unit:	Residential PropertyCommercial PropertyAutoCasualty Mobile Home Property
Type of Adjustment:	Limited Full
Loss Description: Characters left:
VIN #:
Deductible:
Wind Deductible:
Coverage ABuildingBusiness Personal PropertyDebris RemovalBusiness InterruptionComprehensiveCollisionDwellingUPPProperty DamageBodily InjuryLiabilityALEFire Dept. ChargesMedical PaymentsMachinery & EquipmentExtra ExpenseContents / Stock
Coverage BBuildingBusiness Personal PropertyDebris RemovalBusiness InterruptionComprehensiveCollisionDwellingUPPProperty DamageBodily InjuryLiabilityALEFire Dept. ChargesMedical PaymentsMachinery & EquipmentExtra ExpenseContents / Stock
Coverage CBuildingBusiness Personal PropertyDebris RemovalBusiness InterruptionComprehensiveCollisionDwellingUPPProperty DamageBodily InjuryLiabilityALEFire Dept. ChargesMedical PaymentsMachinery & EquipmentExtra ExpenseContents / Stock
Coverage DBuildingBusiness Personal PropertyDebris RemovalBusiness InterruptionComprehensiveCollisionDwellingUPPProperty DamageBodily InjuryLiabilityALEFire Dept. ChargesMedical PaymentsMachinery & EquipmentExtra ExpenseContents / Stock
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