Assignment Form - Property Loss
Please enter the following information. We will acknowledge receipt within 24 hours and contact your insured within the same time period.
Company Information
Your Name
Insurance Company
Mailing Address
Address Continued
City
State
Zip Code
Phone
Fax
E-mail
Report To: (name)
Agency Information
Agency Name
Agency Phone Number
Agency Contact
Assignment Information
Loss Location
Traverse City
Other
Other City
Type of Assignment
Full Assignment
Limited Assignment
Describe if Limited Assignment
Claim Information
Claim Number
Date of Loss
Loss Type
Description of Loss
Policy Information
Policy Number
Effective Policy Dates
Building Coverage Limits
A.P.S. Coverage Limits
Contents Coverage Limits
ALE Coverage Limits
Commercial Building Coverage Limits
Commercial Contents Coverage Limits
Commercial Business Income Coverage Limits
Type of Policy
Homeowners Policy
Dwelling Policy
Commercial Package Policy
Other Policy Type
Other Policy Description
Deductible Amount
$100.00
$250.00
$500.00
$1,000.00
Other
Other Deductible
Forms
Insured Contact Information
Insured Name
Street Address
Address Continued
City
State
Zip Code
Residence Phone
Business Phone
Contact Name
Contact Phone
Mortgagee
Contact company a.s.a.p. to discuss loss
No
Yes
Comments