Casualty Assignment Form

Please note: * denotes fields that are required to be filled in.

Name: *
E-mail: *
Company: *
Company Address:
City: *
State / Province:
ZIP Code:  
Phone: *
Fax: 
Policy #:
Effective dates (mm/dd/yy):
  to  
Claim #:      
Date of Loss (mm/dd/yy):
Time of Loss: AM  PM
Assignment Type
Full Assignment Please investigate and handle all exposures to conclusion.
Further Instructions:
Task Assignment Please complete the following tasks:
Statements
Signed Statement Recorded Statement by Phone Recorded Statement in Person
  Named Insured   Claimant(s)  
  Insured Driver   Claimant Driver  
  Insured Passenger(s)  Claimant Passenger(s)
  Witness(es)      
Records/Reports/Documentation
  Police Report   Medical Authorization  
  Fire Report   Wage Authorization  
  DMV - Driver Records   Medical Records  
  DMV - Vehicle Records   Employer Wage Records
  Other:      
Scene/Photographs/Diagram
  Scene Photos   Claimant Vehicle(s) Photos
  Scene Diagram   Claimant Photo
  Insured Vehicle Photos   Canvass for Witnesses
Other Investigation
  Insured Vehicle Appraisal   Claimant Vehicle(s) Appraisal
  Obtain Insured Vehicle Estimate   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:
State:
ZIP Code:
Owner's Phone:  
Driver's Name:
Driver's Address:
State:
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:

Claimant Property Damage
 
Description: (Make and Model if Auto)
Other Vehicle or Property Insured? Yes No
Company or Agency Name:
Policy #:
Owner/Claimant:
Owner's Address:
State:
Driver's Name: (if Auto Loss)
Check if Driver is same as Owner Yes No
Driver's Phone:
Describe Damage:
Estimate Amount:
Where 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)
 
#1 Name:
Address:
State:
Zip Code:
Phone:
Age:   
   Pedestrian    Insured Vehicle       Adverse Vehicle
Type and Extent of Injury:
#2 Name:
Address:
State:
Zip Code:
Phone: Age:  
   Pedestrian    Insured Vehicle       Adverse Vehicle
Type and Extent of Injury
Additional Injured Parties?  Yes        No
(If yes, please include information under "Further Information or Instructions" below)

Witnesses
#1 Name:
Address:
City:
State:
Phone:
   
#2 Name:
Address:
City:
State:
Phone:
Additional Witnesses? Yes    No
  (If yes, please include information under "Further Instructions" below.)
Further Information or Instructions: