Auto Assignment Form Name: Email: Company: Company Address: City: State: AZ AL AK AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA MA MD MI ME MN MO MS MT NE NC NH NJ NV NY ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip: Phone: Fax: Policy Number: Effective Dates: (mm/dd/yy) to Claim #: Date of Loss: (mm/dd/yy) Time of Loss: AM PM Insured Name: Address: City: State: AZ AL AK AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA MA MD MI ME MN MO MS MT NE NC NH NJ NV NY ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip: Home Phone: Business Phone: Person To Contact: Contact's Phone: Collision Deductible: Comprehensive Deductible: Vehicle Make: Vehicle Model: Vehicle Year: ID #: Plate #: Description of Damage: Location of Vehicle: Claimant Claimant Name: Address: Phone Number: Vehicle Make: Vehicle Model: Vehicle Year: ID #: Plate #: Description of Damage: Location of Vehicle: Instructions: