Assignment Form - Property Loss

 

Please complete the following information. We will contact you and acknowledge receipt within 24 hours.

Insurance Company Information:

Insurance Company

Address, 

City, State, Zip

Adjuster Name
Adjuster Phone #
Adjuster e-mail address

Policy Information

Company
Policy Number
Effective Policy Dates
Coverage Amount
Type of Coverage
Deductible Amount
Forms

Claim Information

Claim Number
Date of Loss
Loss Type
Description of Loss
Reported By

Insured Contact Information

Insured Name
Street Address
Address (cont.)
City
State
Zip/Postal Code
Residence Phone
Business Phone
Contact Name
Contact Phone
Contact Location

Mortgagee

Additional information to follow via fax

Comments / Special Instructions

THIS IS A SECURE AND PRIVATE COMMUNICATION

The information in this electronic mail ("e-mail") message is confidential and for the use of only the named recipient. The information is protected by privilege, work product immunity or other applicable law. If you are NOT the intended recipient, the retention, dissemination, distribution or copying of this e-mail message is strictly prohibited. If you receive this e-mail message in error, please notify us immediately by telephone at, toll free,  (888) 584-3494 or by e-mail to assignments@southwestclaims.com