Online Assignment Form

Submit an online assignment by filling in the form below. Thank you.

Name:

Company:

Telephone:

Email:

Is this an SIU investigation?

yes
no

Is this a coverage investigation?

yes
no

Insured Name:

Adverse Party Name:

Policy #:

Claim #:

Date of Loss:

Services Requested

Statements:

Insured
Claiment
Witness
Other