Haig & Lewin Investigators/Adjusters

Specializing in Northern
and Central California

Friday May 09 2008

Property Claims 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:
Property Assignment:
*Insured Name:
*Address:
*City:
*State:
*Zip:
*Telephone Number:
Loss Location:	Check here if same as above
Address:
City:
State:
Zip:
*Policy Dates:
Agent:
*Coverage Form Numbers:
Coverages:	Building Other Structures Personal Property Additional Living Expense Other:
*Deductible:
*Policy Limits:
*Description of Loss:
*Handling Instructions:
Additional necessary information is being:	Faxed E-Mailed Sent By Mail Have Adjuster Contact Examiner

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