New Assignment Form

To send us a new assignment, please fill out the form below. You will receive a confirmation email, once the form is submitted. If you have any questions, please call us at (877) CPA-SURE.
1. Tell us about yourself.
Your Name
 Email Address
2. Tell us about the assignment.
Claim Number
 Business Name
Date of Loss

Type of Assignment

(Hold Ctrl for multiple selections)

Loss Period (for Income Loss)
City of Loss
State of Loss
3. Tell us who to contact.
Name
 Phone Number
Alternate Phone Number
4. Tell us about any special issues.
If the policy has a coinsurance condition, waiting period, fractional monthly limit, ordinary payroll exclusion, or any other policy conditions, let us know.
5. Tell us if you have associated documents.
Yes, there are documents associated with this assignment.

You will receive a confirmation e-mail containing detailed instructions on submitting the documents to us.