Casualty Assignment Form
Date (mm/dd/yyyy):
Name:
E-mail:
Company:
Company Address:
City:
State: Zip:
Phone:
Fax:
Policy Number:
Effective Dates (mm/dd/yy): to
Claim Number:
Date of Loss (mm/dd/yy):
Time of Loss: AM PM

Insured
Name:
Address:
City:
State: Zip:
Home Phone:
Business Phone:
Person To Contact:
Contact's Phone:

Facts
Loss Location:
Description of Loss or Accident:

Policy Information
Bodily Injury:
Property Damage:
Combined Single Limit:
Medical Payments:
Comprehensive Deductible:
Collision Deductible:
Other Deductibles:
Loss Payee (if none, please indicate):

Insured Vehicle
Vehicle Number:
Year:
Make:
Model:
Plate Number:
VIN Number:
Owner's Name:
Owner's Address:
City:
State: Zip:
Owner's Phone:
Driver's Name:
Driver's Address:
City:
State: Zip:
Driver's Phone:
Relation to Insured:
Driver's License Number:
Date of Birth (mm/dd/yy):
Describe Damage:
Repair Estimate:
Where can vehicle be seen:
When:

Property Damage
Description:
Other Vehicle or Property Insured: Yes No
Company or Agency Name:
Policy Number:
Owner:
Owner's Address:
City:
State: Zip:
Driver's Phone:
Describe Damage:
Estimate Amount:
Where can vehicle be seen:
More than one adverse vehicle: Yes No
(If yes, please include information under "Further Information or Instructions below)

Injured Parties
#1 Name:
Address:
City:
State: Zip:
Phone:
Age:
Pedestrian Insured Vehicle Adverse Vehicle
Extent of Injury:
#2 Name:
Address:
City:
State: Zip:
Phone:
Age:
Pedestrian Insured Vehicle Adverse Vehicle
Extent of Injury:
Additional Injured Parties: Yes No
(If yes, please include information under "Further Information or Instructions" below)

Witnesses
#1 Name:
Address:
City:
State: Zip:
Phone:
Age:
#2 Name:
Address:
City:
State: Zip:
Phone:
Age:
Further Information or Instructions: