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Workers' Compensation Assignment Form
Please complete and submit the following information regarding your Workers' Compensation assignment

Your assignment will be sent to our HOTLINE

To submit an assignment to a different location, please select the location


NOTE: Fields marked with an asterisk (*) are required.

Location of Adjuster Assignment
City:
State:

Submitted By Contact Information
First Name:*
Last Name:*
Phone:*
Fax:*
EMail:*

Submitted By Company Information
CIA Customer #:
First Name:*
Last Name:*
Company Name:*
Street Address:*
Street Address (cont):
City:*
State / Province:*
Zip / Postal Code:*
Contact Phone:*
Contact Fax:*
Contact EMail:*

Coverage

Loss Information
Date of Accident:*  
Customer Claim #:
Location of Accident:
Brief Description of Loss:*
(limited to 70 lines of text)

Employer Information
Employer Name:*
Date Accident Reported
to Employer:*
Contact First Name:
Contract Last Name:
Employer Address:
Employer Address (cont):
City:
State / Province:
Zip / Postal code:
Employer Work Phone:

Claimant Information
Claimant First Name:
Claimant Last Name:
Claimant Address:
Claimant Address (cont):
City:
State:
Zip / Postal Code:
Claimant Home Phone:
Claimant Work Phone:
Male / Female:
Social Security Number:
Date of Birth:
Occupation:
Investigation Type
Action(s) to take /
Special Instructions
(Limited to 70 lines of text)
Attach a file to this assignment
(cannot exceed 4 MB): 		 
Preferred Method of confirmation from CIA:
Please click the Submit button only once. It may take a few minutes for your claim to be processed. You will receive a confirmation once your assigment has been sent.



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