Property Assignment Form
Name:
Email:
Company:
Company Address:
City:
State: 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: Zip:
Home Phone:
Business Phone:
Person To Contact:
Contact's Phone:

Facts
Loss Location:
Description of Loss:

Policy Information
Applicable Limits:
Deductible:
Policy Forms Endorsements:

Full Assignment
Special Instructions:
Limited Assignment: Non Waiver
Coverage Investigations
Official Reports
Photos
Determine Cause and Origin
Prepare Scope / Estimate
Obtain Statements from
ACV/ RCV Evaluation
Diagram
Agreed Price
Investigation Subrogation
Dispose of Salvage
Other
Further Information or Instructions: