Property Loss Type of Property Involved ResidentialCommercialIndustrial Date of Loss Claim Number Policy Number Cat Code Description of Loss General Assignment Instructions First Name Last Name Client Company Name Mailing Address Building/ Suite City State Zipcode First Name Middle Name Last Name Phone Number Other Phone Number Fax Instructions/ Other Information Regarding Insured Coverage A Coverage B Coverage C Coverage D Other Agent First Name Middle Name Last Name Agency/ Broker Company Name Address 1 Address 2 City State Zipcode Phone Number Other Phone Number Fax Instructions/ Other Information Regarding Insured Additional party is Claimant Witness Other Agent First Name Middle Name Last Name Company Address 1 Address 2 City State Zipcode Phone Number Fax Instructions/ Other Information Regarding Insured Confirm Assignment Receipt Email Phone 1st Report Report Within 1-3 Days 3-7 Days 7-15 Days 15-30 Days Send