The fields in RED are required before you can submit your assignment.   If a required field is not applicable to your assignment enter "na". When you have submitted the assignment, a confirmation window  will open.  Use your print icon to print a copy for your file if needed. What is the level of the assignment? Damage Appraisal only Limited Full Adjustment Special please descibe: What line of Business? General Liability Homeowners Property Homeowners Liability Inland Marine Commercial Property Other If Other please describe: Description of Loss: Date of loss: Location of Loss: Claim information and scope of work requested: The fields in RED are required before you can submit your assignment. Adjuster: Phone: Client mailing address: Street 1: Street 2: City: State: Select One Alabama Alaska Alberta, Canada Arizona Arkansas California Canada-Alberta Canada-New Brun Canada-Ontario Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Ontario, Canada Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington D.C. West Virginia Wisconsin Wyoming Other Zip Code : FAX:  Email: Cell Phone: Claim#: Policy#: DED1: DED2: Insured: Contact: Phone: Address: Street 1: Street 2: City: State: Select One Alabama Alaska Alberta, Canada Arizona Arkansas California Canada-Alberta Canada-New Brun Canada-Ontario Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Ontario, Canada Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington D.C. West Virginia Wisconsin Wyoming Other Zip Code : Claimant: Contact: Phone: Address: Street 1: Street 2: City: State: Select one Alabama Alaska Alberta, Canada Arizona Arkansas California Canada-Alberta Canada-New Brun Canada-Ontario Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Ontario, Canada Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington D.C. West Virginia Wisconsin Wyoming Other Zip Code : This is a priority assignment. Please contact me as soon as possible regarding this matter.

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