NEW ASSIGNMENT FORM
ADJUSTER / CLAIM INFORMATION
Insurance Company:
Adjuster Name:
Independent Company:
Insurer Claim No.
Adjuster Claim No.
Date Received:
Date Loss:
Loss Estimate: $
Policy Limit: $
(For the first submission only)
Billing Address:
City:
Province:
Postal Code:
Telephone:
Cellular:
Fax Number:
Email Address:
Claim Type:
Site Visit Required: YesNo
Safety Issues? / Details:
Contractor Company:
Contact Name:
Telephone:
INSURED INFORMATION
Name(s):
Address:
Telephone (Home):
Telephone (Business):
Telephone (Cellular):
E-Mail:
NOTES

e-xclaim Contents Management System
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