Assignment Form.

Please fill out this form with brief description of your appraisal request or claim information with your inquiry.

Claim # *

Date Assigned *

Date of Loss *

Independent Adjusting Company *

Mailing Address *

City *

Province *

Postal Code *

Direct Phone *

Fax

E-Mail *

Please Inspect *

Insured Name *

Insured Home Phone *

Insured Work Phone *

Third Party Name

Third Party Home Phone

Third Party Work Phone

Vehicle Description (Year, Make, Model) *

Location (Shop, Tow Yard, etc) *

Serial Number *

Colour *

License *

"WOP" *

OK To Release To Owner Or Shop? *

Damage Description *

Confirm Animal Impact

Confirm Hit And Run Damage

Please Confirm Number of Occurrences

Please Complete Auto Source if TL

Please arrange For Towing

Please call back with quote for inspection

Do Not Release Appraisal to Owner or Shop

Low Impact Report Required

Please remove salvage to

Misc Details

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