Home Assign a Claim Casualty Assignment Form
Casualty Assignment (AL, GL, WC, etc.)

Please provide as much information about the claim as possible
Required fields are marked by the symbol Required Fields
If you do not have the information for a required field, please enter “unknown”
  Step 1
Basic Information  
   Step 2
Insured Information  
   Step 3
Claimant Information  
 

Client Information/Reporting Address
Required FieldsClient Company Name
Required FieldsFirst Name
Required FieldsLast Name
Required FieldsMailing Address
Building/Suite
Required FieldsCity
Required FieldsState
Required FieldsZip
Required FieldsPhone #
Extn.
Required FieldsFax #
Required FieldsEmail Address

Claim Details and Assignment Type
Required FieldsDOL(mm/dd/yyyy)
Required FieldsClaim/file #
Policy #
CAT Code
Required FieldsDescription of Loss/Peril
Required FieldsGeneral Assignment Instructions
 
Casualty Assignment (AL, GL, WC, etc.)

Please provide as much information about the claim as possible
Required fields are marked by the symbol Required Fields
If you do not have the information for a required field, please enter “unknown”
  Step 1
Basic Information  
   Step 2
Insured Information  
   Step 3
Claimant Information  
  

Insured Name and Contact Information
Required FieldsInsured First Name
Required FieldsLast Name
Company Name
Address 1
Address 2
City
Required FieldsState
Zip
Required FieldsPhone #
Extn.
Other Phone
Extn.
Fax
 
Instructions/Other Insured Information
 
 
Casualty Assignment (AL, GL, WC, etc.)

Please provide as much information about the claim as possible
Required fields are marked by the symbol Required Fields
If you do not have the information for a required field, please enter “unknown”
  Step 1
Basic Information  
   Step 2
Insured Information  
   Step 3
Claimant Information  
  

Claimant #1 Information

Required FieldsFirst Name
Required FieldsLast Name
Company Name
Address 1
Address 2
City
Required FieldsState
Zip
Required FieldsPrimary #
Extn.
Secondary #
Extn.
Cell#
Fax#
Instructions/Other Information Regarding Claimant
 
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