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If you would like to submit an assignment, please use this form.

Company Name: *Required Field* Adjuster: *Required Field* Adjuster's Phone Number: *Required Field* Adjuster's Email: *Required Field* Claim Number: Type of Loss: *Required Field* Date of Loss: (Dy/Mo/Yr) *Required Field* Assignment Instructions/ Requirements *Required Field* Location of Loss: Street Address City State Zip Code AKALAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWY Description of Loss: Insured Name & Address: Name Street Address City State Zip Code AKALAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWY Home Phone Cel. Phone Business Phone Claimant Name & Address: Name Street Address City State Zip Code AKALAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWY Home Phone Cel. Phone Business Phone