Casualty Investigation Claim Type Auto LiabilityGeneral LiabilityWorkmans CompOther Date of Loss Claim Number Policy Number Assignment Type Limited Assignment Full Assignment Description of Loss General Assignment Instructions Insured Do Not Contact Interview Only Recorded Statement Written Statement Include Summary In-Person Phone Claimant Do Not Contact Interview Only Recorded Statement Written Statement Include Summary In-Person Phone Witnesses Do Not Contact Interview Only Recorded Statement Written Statement Include Summary In-Person Phone First Name Last Name Client Company Name Mailing Address Building/ Suite City State Zipcode Insured First Name Middle Name Last Name Phone Number Other Phone Number Fax Instructions/ Other Information Regarding Insured Claimant First Name Middle Name Last Name Company Name Address 1 Address 2 City State Zipcode Phone Number Other Phone Number Fax Instructions/ Other Information Regarding Insured Are there additional claimants and/ or other parties involved? Yes No Send
