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CASUALTY INVESTIGATION

  • Please provide as much information about the claim as possible
  • Required fields are marked by the * symbol.
  • If you do not have the information for a required field, please enter "unknown".
Claim Details and Assignment Type
* DOL (mm/dd/yyyy) * Claim # Policy #

*
Claim Type

Description of Loss
Auto Liability
General Liability
Workmans Comp
Other

* Assignment Type

* General Assignment Instructions
Limited Assignment
Full Assignment

Special Instructions for Statements/Interviews (optional below)
  Do Not
Contact
Interview
Only
Recorded
Statement
Written
Statement
Include
Summary
In-
Person
Phone
Insured
Claimant
Witnesses


Client Information/Reporting Address
* Client Company Name

* First Name

* Last Name

* Mailing Address

Building/Suite

* City

* State

* Zip


Insured Name and Contact Information:
* Insured First Name Middle * Last Name

* Phone #

Other Phone #

Fax #

Instructions/Other Information Regarding Insured


Claimant Information - Primary
* Claimant First Name Middle * Last Name

Company Name

Address 1

Address 2

City

State

Zip

* Phone #

Other Phone #

Fax #

Instructions/Other Information Regarding The Primary Claimant

* Are There Additional Claimants and/or Other Parties Involved? Yes No

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