Casualty Claim

DOL* *

Claim #* *

Policy #* *

Select a type

Auto Liability
General Liability
Product Liability
Other

Description of loss

Assignment Type

Limited Assignment
Full Assignment

General Assignment Instructions

Do Not Contact

Insured
Claimant
Witnesses

Interview Only

Recorded Statement

Written Statement

Include Summary

In-Person

Phone

Client Company Name

First Name

Last Name

Mailing Address

Buildling/Suite

City

State

Zip / Post Code

Phone

Fax

Email

Instructions/Other Information Regarding Client

Insured First Name

Middle

Last Name

Company Name

Address 1

Address 2

City

State

Zip / Post Code

Phone

Phone 2

Fax

Email

Instructions/Other Information Regarding Insured

Claimant First Name

Midddle

Last Name

Company Name

Address 1

Address 2

City

State

Zip / Post Code

Phone

Phone 2

Fax

Email

Are There Additional Claimants and/or Other Parties Involved?

Yes
No

Instructions/Other Information Regarding Claimant

Upload Related Document

Claim Details and Assignment Type

Claim Type & Description

Assignment Type & Instructions

Special Instructions for Statements/Interviews (optional below)

Client Information / Reporting Address

Insured Name & Contact Information

Claimant Information - Primary