Casualty Assignment Form Casualty Assignment Please note: * denotes fields that are required to be filled in. Name * Email * Company * Company Address City * State / Province ZIP Code Phone Number * Fax Number Policy # Effective Dates (mm/dd/yy) Claim # Date of Loss (mm/dd/yy): Time of Loss 121234567891011 : 0030 AMPM Assignment Type Assignment Type Full Assignment Please investigate and handle all exposures to conclusion. Further Instructions: Assignment Type Task Assignment Please complete the following tasks Statements Signed Statement Recorded Statement by Phone Recorded Statement in Person Named Insured Insured Driver Insured Passenger(s) Claimant(s) Claimant Driver Claimant Passenger(s), Witness(es) Witness(es) Records/Reports/Documentation Police Report Fire Report DMV - Driver Records DMV - Vehicle Records Medical Authorization Wage Authorization Medical Records Employer Wage Records OtherOther Scene/Photographs/Diagram Scene Photos Scene Diagram Insured Vehicle Photos Claimant Vehicle(s) Photos Claimant Photo Canvass for Witnesses Other Investigation Insured Vehicle Appraisal Obtain Insured Vehicle Estimate Claimant Vehicle(s) Appraisal Obtain Claimant Vehicle(s) Estimate Court Check Case #/City/County: Insured Name Address City State Zip Code Residence Phone Cell Phone Business Phone Person to Contact Facts Location of Loss Description of Loss or Accident Policy Information Bodily Injury Property Damage Combined Single Limit Medical Payments Comprehensive Deductible Collision Deductible Other Deductibles Loss Payee (if none, so indicate) Insured Vehicle (if Auto Loss) Vehicle # Year Make Model Plate # VIN # Owner's Name Owner's Address Owner's City Owner's State Owner's Zip Code Driver's Name Driver's Address Driver's City Driver's State Driver's ZIP Code Driver's Phone Relation to Insured Driver's License # Date of Birth (mm/dd/yy) Describe Damage Repair Estimate Where can vehicle be seen? When? Time 121234567891011 : 0030 AMPM Claimant Property Damage Description: (Make and Model of Auto) Other Vehicle or Property Insured? Yes No Company or Agency Name Policy # Owner/Claimant Owner's Address Owner's City Owner's State Owner's ZIP Code Driver's Name: (if Auto Loss) Check if Driver is same as Owner Yes No Driver's Phone Describe Damage Estimate Amount When can vehicle be seen More than one adverse vehicle? Yes No (If yes, please include information under "Further Information or Instructions" below) Injured Parties (Insured or Claimant) Claimant #1 Name Address City: State Zip Code Phone Number Age Radio Buttons Pedestrian Insured Vehicle Claimant Vehicle Type and Extent of Injury Claimant #2 Name Address City: State Zip Code Phone Number Age Radio Buttons Pedestrian Insured Vehicle Claimant Vehicle Type and Extent of Injury Additional Injured Party? Yes No (If yes, please include information under "Further Information or Instructions" below) Witnesses Witnesses #1 Name Address City: State Zip Code Phone Number Witnesses #2 Name Address City: State Zip Code Phone Number Additional Witnesses? Yes No (If yes, please include information under "Further Information or Instructions" below) Further Information or Instructions: Further Information or Instructions: Uploads File Upload Drop a file here or click to upload Choose File Maximum file size: 5MB File Upload Drop a file here or click to upload Choose File Maximum file size: 5MB File Upload Drop a file here or click to upload Choose File Maximum file size: 5MB File Upload Drop a file here or click to upload Choose File Maximum file size: 5MB reCAPTCHA If you are human, leave this field blank.
