Welcome to Haig & Lewin, Investigators/Adjusters Serving Greater California

Wednesday September 08 2010


Home Offices Submit a Loss Adjusters Training Contact Glossary



General Liability Assignment

***IMPORTANT NOTE: ***

Your browser must be set to allow javascript for this form to work properly and send the information you want to send. Please change your browser to allow javascript before continuing.
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:
General Liability Assignment:
*Insured Name:
*Address:
*City:
*State:
*Zip:
*Insured Contact:
*Telephone Number:
Loss Location:
*Address:
*City:
*State:
Zip:
*Claimant Name:
Address:
City:
State:
Zip:
Telephone Number:
Injuries:

No

Yes
Represented:

No

Yes
Attorney Name:
Address:
City:
State:
Zip:
Phone:
Witness Name, Addresses, & Phone Numbers:
*Description of Loss:
*Handling Instructions:
Additional necessary
information is being sent as follows:

Faxed

E-Mailed

Sent By Mail

Have Adjuster Contact Examiner

 





© 2006 Haig & Lewin, Inc. All rights reserved. Contact UsPrivacy PolicyLegal Info