Casualty Referral Form

Please provide the appropriate information below.

Report To:
Name
Title
Company
Street Address
City
State
Zip Code
Telephone
Fax
Email
* * *
* * *
Claim Number
Policy Number
Deductible


Assignment Type: Special Instructions:
Limited Photo/Diagram Scene
Full Investigation Statement Insured
Full Adjustment Statement Claimants
Appraisal Only Statement Witnesses
Fire/Police Reports
DMV Records
Court Records
Medical Records Authorization
Medical Records
Wage Authorization
Employment Records


Other Instructions/Information
* * *
* * *
Claim Information:
Date of Loss
Facts of Loss
Insured
Insured Address
Insured Telephone
Claimant Information
Witness Information


Appraisal Instructions:
Insured Vehicle
Claimant Vehicles
Agreed Repair Cost
Location of Vehicles


Today's Date

Click here when your information input has been completed