Assignment Form
Today´s Date:
Time:
Date of Loss:
Company:
Address:
Adjuster:
Adjuster´s Email Address:
Phone Number:
Claim / Policy Number:
Insured:
Address:
Home Phone Number:
Work Phone Number:
Cell Number:
Vehicle:
VIN:
Vehicle Location:
Location Phone Number:
Deductible:
$
None
Waived
Deductible Type:
Collision
Comprehensive
Other
Insured pays HST:
Yes
No
43R Endorsement:
Yes
No
WOP:
Yes
No
Damage Area:
Comments:
reCaptcha:
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