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New Assignment for ASSOCIATED CLAIM SERVICE, INC.
Your Contact Information
First Name
Last Name
Company
Address (Line 1)
(Line 2)
City
State	AAABAEAKALAPARAZBCCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMBMDMEMIMNMOMSMTNBNCNDNENFNHNJNMNSNTNVNYOHOKONORPAPRQCRISCSDSKTNTXUTVAVTWAWIWVWYYT
ZIP
Phone:
eMail:
New Assignment Information
Your Claim #:
Assignment Instructions: Characters left:
Insured's Information
Policy #:
Phone #:
Alternate Phone #:
Company:
First Name:
Last Name:
Street Address:
Address 2:
City:
State:	AAABAEAKALAPARAZBCCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMBMDMEMIMNMOMSMTNBNCNDNENFNHNJNMNSNTNVNYOHOKONORPAPRQCRISCSDSKTNTXUTVAVTWAWIWVWYYT
Zip:
Mortgagee:
Loss Location
Street Address:
Address 2:
City:
State:	AAABAEAKALAPARAZBCCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMBMDMEMIMNMOMSMTNBNCNDNENFNHNJNMNSNTNVNYOHOKONORPAPRQCRISCSDSKTNTXUTVAVTWAWIWVWYYT
Zip:
Claimant Information (if applicable)
First Name:
Last Name:
Phone:
Street Address:
Address 2:
City:
State:	AAABAEAKALAPARAZBCCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMBMDMEMIMNMOMSMTNBNCNDNENFNHNJNMNSNTNVNYOHOKONORPAPRQCRISCSDSKTNTXUTVAVTWAWIWVWYYT
Zip:
Agent Information Show | Hide
First Name:
Last Name:
Company:
Office Phone:
Cell Phone:
Street Address:
Address 2:
City:
State:	AAABAEAKALAPARAZBCCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMBMDMEMIMNMOMSMTNBNCNDNENFNHNJNMNSNTNVNYOHOKONORPAPRQCRISCSDSKTNTXUTVAVTWAWIWVWYYT
Zip:
Country:
Loss Information
Date of Loss:
Type of Loss:	ANIMAL BITEANIMAL DAMAGEAPPRAISALAUTO LIABILITYBODILY INJURYBUSINESS INTERRUPTIONCARGOCOLLAPSECOLLISIONCONSULT/EXPERT REVIEWEXPLOSIONFATALITYFIREFREEZINGFUEL/CHEMICAL SPILLHAILICE DAMINVENTORYLIABILITYLIGHTNINGMEDIATIONMOLDPOWER OUTAGEPOWER SURGEPROPERTY PROPERTY DAMAGESCENE INVESTIGATIONSEWER BACKUPSMOKE DAMAGESNOWMOBILESOOT DAMAGESUMP PUMP/OVERFLOWSURVEILLANCETHEFTUIM/UMUMPIREVANDALISMWATERWEIGHT OF ICE/SNOWWINDWORK COMP
Unit:	Residential PropertyCommercial PropertyResidential LiabilityCommercial LiabilityPersonal AutoCommercial AutoWorkers CompensationHeavy EquipmentFarm Equipment/ImplementATV/UTVBoatCamper/RVTrailerMotorcycleRecreational Vehicle
Type of Adjustment:	Limited Full
Loss Description: Characters left:
VIN #:
Deductible:
Wind Deductible:
Coverage ABuilding
Coverage BBuilding
Coverage CBuilding
Coverage DBuilding
Endorsements:
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