General Liability Assignment Form

Assignment City, State, and Country
City
State / Province
Country

Name
First Name*
Last Name*
Contact Information
Phone Number*
Email Address*
Cell Phone Number
Fax Number
Company
Company Name*
Branch / Office Number
Address
Address Line 1*
Address Line 2
City*
State / Province*
ZIP / Postal Code*
Country*

Name
First Name
Last Name
Contact Information
Phone Number
Email Address
Cell Phone Number
Fax Number

Policy Details
Policy Number
Policy Effective Date

Customer Claim Number
Brief Description of Loss*
Date of Loss*
Location of Loss
Were Police Called?
Name of Police Dept.
Was Fire Dept. Called?

Insured Person / Company*
Name
Insured First Name
Insured Last Name
Insured Address
Insured Address Line 1
Insured Address Line 2
Insured City
Insured State / Province
Insured ZIP / Postal Code
Insured Country
Contact Information
Insured Home Phone Number
Insured Email Address
Insured Cell Phone Number
Insured Work Phone Number

Description of Injury(ies)
Injured Party
Injured Party First Name
Injured Party Last Name
Injured Party Phone Number
Injured Party Email Address

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Attach file(s) to this assignment
Action(s) to take / Special Instructions

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General Liability Assignment Form

Location of Adjuster Assignment

Submitted By

Report To (if different from above)

Policy Information

Loss Information

Insured Information

Claimant Information

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