Date (mm/dd/yy):
 
Name:*
 
Email:*
 
Company:*
 
Company Address:
 
City: *
 
State / Province:
 
ZIP Code:
 
Phone: *
 
Fax: 
 
Policy #:
 
Effective dates
   To  
Claim #:
 
Date of Loss
 
Time of Loss:
 
   
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 or Accident:
 
   
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
 
 
Dispose of Salvage
 
 
Other  
   
Further Information or Instructions:
   
 

 
 
Sam Hooper and Associates 2016