Catastrophe Claims Services - DMA Claims Services

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Catastrophe Assignment Form

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


Date (mm/dd/yy):
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

Insured

Name:
Address:
City:
State:
Zip Code:
Residence Phone:
Person to Contact:
Business Phone:
Contact Phone:

Claimant

Name:
Address:
City:
State:
Zip Code:
Residence Phone:
Person to Contact:
Business Phone:
Contact Phone:

Facts
Location of Loss:
Description of Loss:

Policy Information

Applicable Limits:		Deductible:
Policy Forms / Endorsements:

Full Assignment

Special Instructions:





	Limited Assignment
		Non Waiver
		Coverage Investigation
		Official Reports
		Photos
		Determine Cause and Origin
		Prepare Scope / Estimate
		Obtain Statements from
		ACV / RCV Evaluation
		Diagram
		Agreed Price
		Investigate Subrogation
		Dipose of Salvage
		Other

	Further Information or Instructions:

DMA Claims Services
Corporate and
Claims Administration

2705 Media Center Drive
Los Angeles, CA 90065
Phone: 323 342-6800
Fax: 323 342-6850
Email: email@dmaclaims.com

DMA Claims Services
Assignments and CAT

2705 Media Center Drive
Los Angeles, CA 90065
Phone: 323 275-2100
Fax: 323 275-2150
Email: email@dmaclaims.com

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