New Assignment Form

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.

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.

Business income loss
Cash loss
Contents loss
Employee dishonesty loss
Extra expense
Inventory loss
Valuable papers loss
Lost income
Receivable loss