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You may fax your new assignment sheet to (916) 686-2574 or you may submit the New Assignment Form below via email.

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NEW ASSIGNMENT FORM
DATE:
 
CLIENT CONTACT INFORMATION
CLIENT:
ADDRESS:
 
CLIENT CONTACT:
PHONE(S):
FAX:
EMAIL:
SUBMITTED BY:
 
ADJUSTER:
ADJUSTER EMAIL:
ADJUSTER PHONE(S):
ADJUSTER FAX:
 
POLICY INFORMATION
INSURANCE COMPANY:
POLICY NUMBER:
POLICY EFFECTIVE DATE:
 
LOSS INFORMATION
DATE OF LOSS:
LOSS TYPE:
DAMAGED PROPERTY:
LOSS LOCATION:
 
CLIENT CLAIM #:
DESCRIPTION OF LOSS:
   
INSTRUCTIONS:
 
INSURED INFORMATION
INSURED:
INSURED CONTACT:
INSURED ADDRESS:
   
PHONE(S):
FAX:
 
CLAIMANT INFORMATION
CLAIMANT:
CLAIMANT CONTACT:
CLAIMANT ADDRESS:
   
PHONE(S):
FAX:
 
ADDITIONAL COMMENTS
 
              




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