ASSIGNMENT INFORMATION FORM #1
Insurance Company:
Name:
Address:
Adjuster's Name:
Adjuster's Contact Info:
Insured's Information:
Name:
Address:
Insured Contact Info:
Claim Number:
Policy Number:
Type of Loss:
Date of Loss:
Equipment/Vehicle Information:
Year:
Make:
Model:
Serial Number:
Coverage (A.C.V. or R.C.):
Limit of Insurance:
Location:
Comments: