Online Assignment Form

Thank you for visiting our online assignment form. Please submit this assignment after the information is filled out. Required items marked with * and in YELLOW. If item not known please enter unknown.

		CLIENT INFORMATION
*	Adjuster's Name:
*	Adjuster's E-Mail:
*	Confirm-Email:
*	Contact Phone:	Ext:
	Contact Fax:
*	Client Name:
*	Mailing Address:
*	City:
*	State:	* Zip Code:

		CLAIM INFORMATION
*	Claim Number:
	Policy Number:
*	Deductable:
*	Date of Loss:
*	Vehicle Type:
*	Type of Loss:
*	Describe Loss:
*	Loss Location:

		SERVICES REQUESTED
	Statements:	InsuredClaimantWitnessOther (describe below)
*	Photos:	Insured VehicleClaimant VehicleProperty DamageScene Invest. (describe below)Other (describe below)
*	Documents:	EstimateACVPolice ReportMedical ReportMed. Wage/AuthCoroner's ReportDeath CertificateOther (describe below)
	Activities:	Skip Trace Locate Attend MSC/Mediation Policy File Court CheckAttend Small ClaimsOther (describe below)

		CONTACT ONE
*	Please Choose:	InsuredClaimantWitnessOther
*	Contact's Name:
*	Home Phone:
*	Work Phone:
	Cell Phone:
*	Street:
*	City:
*	State:	* Zip Code:
	Attorney:
	Attorney Address:
	Attorney Phone:
		Address verified as valid Returned mail at address Party not responding to phone calls Party speaks foreign language (please specify:)

CONTACT TWO (click to expand)


	Please Choose:	InsuredClaimantWitnessOther
	Contact's Name:
	Home Phone:
	Work Phone:
	Cell Phone:
	Street:
	City:
	State:	Zip Code:
	Attorney:
	Attorney Address:
	Attorney Phone:
		Address verified as valid Returned mail at address Party not responding to phone calls Party speaks foreign language (please specify:)

CONTACT THREE (click to expand)

	Please Choose:	WitnessOther (specify)
	Contact's Name:
	Home Phone
	Work Phone:
	Cell Phone:
	Street:
	City:
	State:	Zip Code:
	Attorney:
	Attorney Address:
	Attorney Phone:
		Address verified as valid Returned mail at address Party not responding to phone calls Party speaks foreign language (please specify:)

VEHICLE ONE (click to expand)


	Please Choose:	Insured'sClaimant's
	Year:	Make:
	Model:	Color:
	License Plate:	VIN:
	Point of Impact:
	Location:
	Vehicle Drivable:	YesNo

VEHICLE TWO (click to expand)


	Please Choose:	Insured'sClaimant's
	Year:	Make:
	Model:	Color:
	License Plate:	VIN:
	Point of Impact:
	Location:
	Vehicle Drivable:	YesNo


	ADDITIONAL INSTRUCTIONS:

	PERSONS TO BE COPIED ON REPORTS:

	OK to hire interpreter if neccessary Yes No
	ASSIGNMENT ATTACHMENTS Would you like to attach a file to be sent to us with this assignment (i.e., a police report or a release?) To attach a file, click the Browse or Choose File button and select the file on your hard drive. When you submit the form, the file will be included (for large files, this may take some time.) NOTE: max. file size: 6 MB

	Items will be faxed (describe below)

	PLEASE TELL US HOW WE CAN IMPROVE THIS FORM IMPROVE THIS FORM


Please choose which office you would like your assignment to go to:

Yakima WAPasco WAWenatchee WA

CLIENT INFORMATION

CLAIM INFORMATION

SERVICES REQUESTED

CONTACT ONE

ADDITIONAL INSTRUCTIONS:

PERSONS TO BE COPIED ON REPORTS:

ASSIGNMENT ATTACHMENTS

PLEASE TELL US HOW WE CAN IMPROVE THIS FORM IMPROVE THIS FORM