Claim Assignment Form | S&S Claims Service

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Claim Assignment

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 & Assignment Type

DOL (mm/dd/yyyy)*

Claim #*

Policy #*

CAT Code

Type Of Property Involved

Residential

Commercial

Industrial

Description Of Loss/Peril*

General Assignment Instructions*

Client Information | Reporting Address

Client Company Name*

First & Last Name*

Mailing Address

City/State/Zip*

Phone #*

Email*

Insured Name & Contact Information

Insured First & Last Name*

Insured Company Name

Insured Language

Property Address*

City/State/Zip*

Insured Phone*

Alternate Phone

Insured Email

Policy Information & Coverage Details

COVERAGE A: Limit / Deductible / Coinsurance / Forms

COVERAGE B: Limit / Deductible / Coinsurance / Forms

COVERAGE C: Limit / Deductible / Coinsurance / Forms

COVERAGE D: Limit / Deductible / Coinsurance / Forms

OTHER: Limit / Deductible / Coinsurance / Forms

Other Information Concerning Coverage

Instructions/Other Insured Information

Agent Information

Agent's First, Middle & Last Name

Agent/Broker Company Name

Agent Address

Agent City/ State /Zip

Agent Phone

Agent Other Phone

Agent Fax

Instructions/Other Information Regarding The Agent

Information On Other Parties

Please use the following section for identifying additional parties to the loss, such as eye-witnesses, police officers, attorneys, etc. (Not Required).

Other Party

Claimant

Witness

Other

Other Description

First, Middle & Last Name

Company

Address

City/State/Zip

Phone

Other Phone

Fax