Please use this simple form to submit an assignment to us. We will email you a confirmation and estimated time of completion. Insurance Company Claim InformationCompany Name*Company Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Adjuster name* First Last Adjuster Email* Adjuster Phone*Claim number*Date of Loss* Coverage in question? Yes No N/A Release estimate? Yes No N/A Loss Location/Owner InformationVehicle/Homeowner owner is:* Insured Claimant Owner name*Primary PhoneAlternate PhoneVehicle or Property Loss location* Street Address Address Line 2 City ZIP Code Loss Description/NotesSpecial instructions on this claim EmailThis field is for validation purposes and should be left unchanged.
