New Assignment Form

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Assignments will be confirmed with the claim number and completed ASAP, normally within two business days.

Fields marked with * are required.

Date:

Time:

* Insurance Company:

Adjusting Firm:

Address:

Address 2:

Postal Code/Zip:

City:

* Adjuster:

* Email Address:

* Phone Number:

Fax Number:

Policy Number:

* Claim Number:

* Date of Loss:

* Insured:

Claimant:

* Vehicle - year, make, model:

License Plate:

* Serial Number:

* Vehicle Location:

Address:

Phone Number:

Owner Address:

Owner Phone Number:

Owner Business Number:

Owner Cell Number:

Owner E-Mail Address:

Collision Deductible:

Comprehensive Deductible:

Waived:

None:

Insured pays HST:

Yes No

R43 Endorsement:

Yes No

A19 Policy Endorsement:

Yes No
Amount:
Currency: CAD USD

* Area of Damage:

Special Instructions:

* 'Without Prejudice,
Not Authorized':

Yes No

Files (PDF):

* Submitter agrees to abide by Terms of Service (click to view)