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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.

Form instructions

To send us a new assignment, please fill out the form to the left. You will receive a confirmation email, once the form is submitted.

If you have any questions, please call us at (877)272-7873.

If the policy has a coinsurance
condition, waiting period,
fractional monthly limit, ordinary
payroll exclusion, or any other
policy conditions, let us know
in the box to the left.

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