SIU Assignment Liability Form

SIU Assignment – Liability

Please note: * denotes fields that are required to be filled in.


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Maximum upload size: 5MB
Drop a file here or click to upload Choose File
Maximum upload size: 5MB
Drop a file here or click to upload Choose File
Maximum upload size: 5MB
Drop a file here or click to upload Choose File
Maximum upload size: 5MB

:


Assignment Type

Please investigate and handle all exposures to conclusion.


Please complete the following tasks


Insured


Facts


Policy Information


Insured Vehicle (if Auto Loss)

:


Claimant Property Damage

(If yes, please include information under "Further Information or Instructions" below)


Injured Parties (Insured or Claimant)

(If yes, please include information under "Further Information or Instructions" below)


Witnesses

(If yes, please include information under "Further Information or Instructions" below)


Further Information or Instructions:

Sending