New Assignment - New Case - Investigation

Client/Adjuster Information

First Name*

Last Name*

Company*

Email Address*

Client Phone Number*

Are you are an IA submitting an assignment? If yes, enter the insurance carrier information below.

Carrier Name*

Carrier Representative*

Email Address*

Phone Number*

Claim Number

Date of loss

Insured's Name

Insured's Phone No.

Insured's Email Address

Loss Location Address

Scope of Assignment

Discipline

Attach File 1

Max. file size: 50 MB.

Attach File 2

Max. file size: 50 MB.

Attach File 3

Max. file size: 50 MB.

Attach File 4

Max. file size: 50 MB.

Attach File 5

Max. file size: 50 MB.

Additional Comments

Comments

This field is for validation purposes and should be left unchanged.