New Assignment

1.) Tell us about yourself.

Mandatory field Your Name*

Mandatory field Email Address*

2.) Tell us about the assignment.

Mandatory field Claim Number*
Date of Loss (MM/DD/YYYY)
Loss Period (for Income Loss)
City of Loss
Mandatory field State of Loss*

Mandatory field Insured's / Claimant's Business Name*
Type of Assignment

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3.) Tell us who to contact.

Mandatory field 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 can attach documents here, or if you prefer another method, you will receive a confirmation e-mail containing detailed instructions on other ways to submit documentation to us.

(Hold Ctrl for multiple selections)