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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
AA
AB
AE
AK
AL
AP
AR
AZ
BC
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MI
MN
MO
MS
MT
NB
NC
ND
NE
NF
NH
NJ
NM
NS
NT
NV
NY
OH
OK
ON
OR
PA
PR
QC
RI
SC
SD
SK
TN
TX
UT
VA
VT
WA
WI
WV
WY
YT
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:
AA
AB
AE
AK
AL
AP
AR
AZ
BC
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MI
MN
MO
MS
MT
NB
NC
ND
NE
NF
NH
NJ
NM
NS
NT
NV
NY
OH
OK
ON
OR
PA
PR
QC
RI
SC
SD
SK
TN
TX
UT
VA
VT
WA
WI
WV
WY
YT
Zip:
Mortgagee:
Loss Location
Street Address:
Address 2:
City:
State:
AA
AB
AE
AK
AL
AP
AR
AZ
BC
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MI
MN
MO
MS
MT
NB
NC
ND
NE
NF
NH
NJ
NM
NS
NT
NV
NY
OH
OK
ON
OR
PA
PR
QC
RI
SC
SD
SK
TN
TX
UT
VA
VT
WA
WI
WV
WY
YT
Zip:
Claimant Information
(if applicable)
First Name:
Last Name:
Phone:
Street Address:
Address 2:
City:
State:
AA
AB
AE
AK
AL
AP
AR
AZ
BC
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MI
MN
MO
MS
MT
NB
NC
ND
NE
NF
NH
NJ
NM
NS
NT
NV
NY
OH
OK
ON
OR
PA
PR
QC
RI
SC
SD
SK
TN
TX
UT
VA
VT
WA
WI
WV
WY
YT
Zip:
Agent Information
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First Name:
Last Name:
Company:
Office Phone:
Cell Phone:
Street Address:
Address 2:
City:
State:
AA
AB
AE
AK
AL
AP
AR
AZ
BC
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MI
MN
MO
MS
MT
NB
NC
ND
NE
NF
NH
NJ
NM
NS
NT
NV
NY
OH
OK
ON
OR
PA
PR
QC
RI
SC
SD
SK
TN
TX
UT
VA
VT
WA
WI
WV
WY
YT
Zip:
Country:
Loss Information
Date of Loss:
Type of Loss:
ATV
ANIMAL DMG
ANIMAL BITE
APPRAISAL
AUTO
AUTO LIAB
BI
BREAK-IN
BURGLARY
BUS INTERRUPTION
CARGO
COLLAPSE
COMP AUTO
EXPLOSION
FATALITY
FIRE
FLOOD
FREEZING
FUEL SPILL
HAIL
ICE DAM
JEWELRY
LIABILITY
LIGHTNING
MOLD
MOTORCYCLE
OVERSPRAY
PHOTOS
POWER OUTAGE
PRODUCTS LIAB
PROPERTY
PROPERTY DMG
SCENE INVEST.
SEWER BACKUP
SMOKE DAMAGE
SNOWMOBILE
SOOT
SUMP PUMP BACKUP
SURVEILLANCE
THEFT
TORNADO
VANDALISM
VEHICLE DAMAGE
WATER
WEIGHT ICE/SNOW
WIND
WORK COMP
CAMPER
GLASS BREAKAGE
COLLISION
DOG BITE
HEAVY EQUIPMENT
CHEMICAL SPILL
MYST.DISAPPEARANCE
INLAND MARINE
PROPERTY DAMAGE LIABILITY
RV INSPECTION
AUTO PHYSICAL DAMAGE
INVENTORY
UMPIRE
MEDIATION
BUSINESS PROPERTY
CONTRACTOR LIABILITY
UIM
POWER SURGE
MEDICAL PAYMENTS
BOAT
EXPERT REVIEW
CONSULT
Unit:
Residential Property
Commercial Property
Residential Liability
Commercial Liability
Personal Auto
Commercial Auto
Workers Compensation
Heavy Equipment
Type of Adjustment:
Limited
Full
Loss Description:
Characters left:
VIN #:
Deductible:
Wind Deductible:
Coverage A
Building
Coverage B
Building
Coverage C
Building
Coverage D
Building
Endorsements:
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