Casualty Assignment Short Form Simple Assignment - Casualty Examiner * Company * Phone Fax Email Address * Claim Number * Date of Loss Facts of loss Insured Name Insured Contact Information Claimant Name Claimaint Contact Information Other Point of Contact (If needed) Loss Location Vehicle Description What would you like us to do? Additional information our adjuster may need Claim Specific Email (If applicable) File Upload Drop a file here or click to upload Choose File Maximum upload size: 20MB File Upload Drop a file here or click to upload Choose File Maximum upload size: 52.43MB File Upload Drop a file here or click to upload Choose File Maximum upload size: 52.43MB If you are human, leave this field blank. Submit
