Haig & Lewin Investigators/Adjusters

Specializing in Northern
and Central California

Friday May 09 2008

Automobile Liability Assignment

To submit an assignment online, please complete the following information. Required fields are marked with *.

CLIENT/INSURANCE COMPANY INFORMATION:

*Assigning Party Name:
*Company Name:
*Address:
*City:
*State:
*Zip:
*Phone:
*Fax:
*Email:
*Claim Number:
Policy Number:
*Date of Loss:
Automobile Liability Assignment:
*Insured Name:
*Address:
*City:
*State:
*Zip:
*Telephone Number:
*Insured Driver Name:
Address:
City:
State:
Zip:
*Telephone Number:
Injuries:	No Yes
Represented:	No Yes
Attorney Name:
Address:
City:
State:
Zip:
Telephone Number:
Insured Vehicle:
*Insured Vehicle Description:
Coverages:
Location of Loss:
*Address:
*City:
*State:
Zip:
Claimant Vehicle:
Claimant Vehicle Description:
Claimant Driver Name:
Address:
City:
State:
Zip:
Telephone Number:
Type of Claim:	PD BI
Represented:	No Yes
Attorney Name:
Address:
City:
State:
Zip:
Telephone Number:
BI Claimant Name:
Address:
City:
State:
Zip:
Telephone Number:
Injuries:	No Yes
Represented:	No Yes
Attorney Name:
Address:
City:
State:
Zip:
Telephone Number:
Witness Name, Addresses, & Phone Numbers:
Facts & Handling Instructions:
Additional necessary information is being:	Faxed E-Mailed Sent By Mail Have Adjuster Contact Examiner

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