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Auto Claimco - New Assignment Form

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Customer Information

Company Name:

Underwriting Company:

Adjuster Name:

Adjuster Telephone:

Adjuster City/Province:

Adjuster Email:

Claim & Policy Number:

Information About Insured

Insured's Name:

Address:

City/Province:

Home Telephone:

Work Telephone:

Information About Vehicle

Date of Loss:

Endorsement 43R:

Deductible Amount:

Type of Loss:

Insured pays GST:

Make / Model / Year:

VIN (last 6 digits):

Plate Number:

Damage Description:

Information on Body Shop

Shop Name:

Address:

City/Province:

Telephone:

Comments:

Re-enter adjuster email:

File uploads:

Auto Claimco - New Assignment Form

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