Assignment InformationFrom Insurance Company Self-InsuredReport To Email Phone Number Fax Claim Number Policy Number Policy Dates Date Of Loss Full Adjustment Investigation Appraisal OnlyInsured InformationFirst Name Last Name AddressAddress Line 1 Address Line 2 City State Zip Code Home Phone Work Phone Insurance InformationType Of Policy Home Owners Farm Owners Commercial Property Dwelling Policy Business Owners OtherIf “Other”, Please Describe Deductible (Basic) $100 $250 $500 $1000 OtherIf “Other”, Please Describe Deductible (Wind/Hail) $100 $250 $500 $1000Mortgage Amount Of Coverage – Building Building Coverage RC? – Select –YesNoAmount Of Coverage – Contents Contents Coverage RC? – Select –YesNoAmount Of Coverage – Other Other Coverage RC? – Select –YesNoCause Of Loss Location Of Loss (If Different From Property Address) Special Instructions, Comments, Or Remarks Submit Form
