Send Us a New Assignment — Western Pennsylvania
Print this form out and fax it back or fill it out online and choose submit

Claim Representative                              Email

Company

Address

City / State / Zip

Phone                                                       Fax

Date of Loss

Claim Number

INSURED

Address

City / State / Zip
Home Phone / Work Phone

CLAIMANT

Address

City / State / Zip
Home Phone / Work Phone

DESCRIPTION

SERVICE REQUIRED
 Full Investigation
 Insured Statement
 Claimant Statement(s)
 Witness Statement
 Medical Authorizations
 Photos
 Diagrams
 Police Report
 Secure Evidence
Auto Appraisal
Witness Location
Complete Scene Work-up
Other ...
Special Instructions