Casualty Claim If you do not have the information for a required field, please enter “unknown”. If you are a human and are seeing this field, please leave it blank. Fields marked with an * are required Claim Details and Assignment Type DOL* * Claim #* * Policy #* * Claim Type & Description Select a type Auto LiabilityGeneral LiabilityProduct LiabilityOther Description of loss Assignment Type & Instructions Assignment Type Limited AssignmentFull Assignment General Assignment Instructions Special Instructions for Statements/Interviews (optional below) Do Not Contact InsuredClaimantWitnesses Interview Only Recorded Statement Written Statement Include Summary In-Person Phone Client Information / Reporting Address Client Company Name First Name Last Name Mailing Address Buildling/Suite City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip / Post Code Phone Fax Email Instructions/Other Information Regarding Client Insured Name & Contact Information Insured First Name Middle Last Name Company Name Address 1 Address 2 City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip / Post Code Phone Phone 2 Fax Email Instructions/Other Information Regarding Insured Claimant Information - Primary Claimant First Name Midddle Last Name Company Name Address 1 Address 2 City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip / Post Code Phone Phone 2 Fax Email Are There Additional Claimants and/or Other Parties Involved? YesNo Instructions/Other Information Regarding Claimant Upload Related Document *
