Moe & Nevin Insurance Adjusters

Casualty / Liability Assignment Form

Client Information:

* Denotes a field that is required

Please send assignment acknowledgement: Yes    No

Name of person entering claim information: *

Name of person to whom to report:

Name of your company: * 

Mailing Address: * 

Line 2 Mailing Address: 

City: *    State:*   Select State Alabama Alaska Arizona Arkansas Armed Forces Asia Armed Forces Europe Armed Forces Pacific California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming   Zip:*   

Phone Number: *       Fax Number: *     

Email Address: 

Claim Number: 

Insured Information:

Insured Name: * 

Insured Address: * 

Insured Address 2:

City: *    State:* Select State Alabama Alaska Arizona Arkansas Armed Forces Asia Armed Forces Europe Armed Forces Pacific California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming      Zip: *  

Loss location if different than insured's address above:

Insured's Home Phone: *       Insured's Alternate #:

Insured's Cell: Insured's email:

Loss Information:

Date of Loss: * 

Description of Loss: 

Please check all that apply:

Take statements from Insured   Take statements from passengers 

Take statements from witness(es)

Take statements from claimants all or

Have statements transcribed all or

Photo accident scene    Handle BI claim

Complete full investigation to events surrounding claim

Obtain all necessary authorizations and obtain reports

send in authorizations and we will obtain reports.

Other