Assignment Submission Form Assignment Submission Form Carrier/Third Party Information Company Name * Company Type * Insurance CarrierThird Party (IA Firm, TPA, Legal)Other Company Type Name * Name First First Last Last Job Title * Claims Manager Phone * Email * Loss Information Claim Number * Date of Loss Loss Description Loss Location Address * Loss Location Address Loss Location Address Loss Location Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Building Type CommercialResidentialAgriculturalIndustrialInstitutional Service(s) Requested Cost Estimate Hail Inspection Property Inspection Roof Inspection Scope Review Desk Review Appraisal | Umpire Clerk-of-the-Works Legal Building Consultant Requested Alex GoughDan DoubravaDustin MeyerHarold AdamsJason OstbyJeff McClurePaul OrigerTerry RyanThomas ElertWill Silva Selecting a BC is not required. Assignment Handling Instructions File Upload Drop a file here or click to upload (property loss notice, estimates, photos, drawings, etc.) Choose File Maximum file size: 10MB Insured Information Contact Insured YesNo Insured Name Insured Name First First Last Last Insured Phone Insured Email Public Adjuster Information Contact Public Adjuster YesNo Public Adjuster Name Public Adjuster Name First First Last Last Public Adjuster Phone Public Adjuster Email Attorney Information Contact Attorney YesNo Attorney Type Defense CounselPlaintiff Counsel Attorney Name Attorney Name First First Last Last Attorney Phone Attorney Email Captcha If you are human, leave this field blank. Submit Start Over
