Loss Assignment Form

Client Contact Information
Your Name
Telephone Number
Fax Number
Email Address

Instructions for Assignment

Commercial Loss Personal Loss

Insured Recorded Statement	Contents List/Inventory
Witness Recorded Statement	Photos of contents
Non-Waiver	Proof of purchases
Photo Structure	Proof of loss
Scope of damage	Statement of claim
Estimate of damage	Police/Fire report
Diagram of structure	Cause and origin
Contractors Bid	Subro investigation
Agreed cost of repair	A.L.E. information
Salvage	Other:

Policy Information
Insurance Company
Policy Number
Effective Policy Dates
Coverage Amount
Type of Coverage
Deductible Amount

Claim Information
Claim Number
Date of Loss
Type of Loss
Description of Loss
Reported By

Insured Information
Insured Name
Insured Address
Insured City, State, Zip	,
Residence Telephone
Business Telephone
Contact Name
Contact Telephone
Contact Business Telephone
Contact Location
Time to contact

Please make sure that the above information is correct before submitting. We thank you for this assignment and the opportunity to serve your interest.