Claim Assignment Form

Please fill in appropriate blanks and submit.  This assignment will be emailed to Specialty Adjusting International at that time.  You will receive a confirmation of the assignment when you press the "submit" button located on the bottom of this page.  Please print it out for your file.  You may also use it as a cover page for any other documents you fax with reference to this claim. You should receive another confirmation from our office within 24 hours of receipt of the assignment, sent  to the email address or FAX number you submit.

                                     

Today's Date   

               

Company Name   
Address
Telephone
FAX
Adjuster Name        
E-mail                   
  
 

 

Insured                     

 

Insured Contact
Insured Address   
Insured Phone
Claim/Policy Number
Date of Loss
Claimant Name:           
Claimant Address
Claimant Telephone

        Description of Assignment/Request:

Please fax additional documents to (561) 747-0022.   
 
Documents Faxed:  Acord    Police Report   Coverage Information  Other Documents
Please fax above documents using the Confirmation page as your cover page.  Thank you for the assignment.
                                                                                                                                    

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Deborah S. Viamontes
Copyright © 2004 [Viamontes Enterprises, Inc]. All rights reserved.
Revised: September 28, 2005 .