Automobile Assignment Form


AUTOMOBILE ASSIGNMENT

 From  Email  Company
 Policy #  Claim #

 Insured  Phone (H)  Phone (W)
 Address  City  ST  Zip
 Contact  Phone (H)  Phone (W)
 Address  City  ST  Zip

 Date of Loss  Time  Authority Contacted  Report #
 Location (Include City & State):

 Description


 Vehicle #  Year  VIN  Plate #  State
 Make  Model  Body Type
 Owner  Phone (H)  (W)
 Address  City  ST  Zip
 Driver  License #  State  Phone (H)  (W)  DOB
 Address  City  ST  Zip
 Relationship to Insured  Purpose of Use  Permission to Use

 Describe Damage

 Estimate Amount  Where Vehicle can be Seen

 Describe Property (if applicable)  Vehicle/Property Insurance Y     Insurance Company
 Vehicle Number (if applicable)  Year  VIN  Plate #  State
 Owner  Phone (H)  (W)
 Address  City  ST  Zip
 Driver  License #  State  Phone (H)  (W)  DOB
 Address  City  ST  Zip

 Describe Damage

 Estimate Amount  Where Vehicle can be Seen

 Name & Address  Phone  INS
VEH
 OTH
VEH
 PED  AGE  Extent of Injury
             
             
             

 Name & Address  Phone  INS
VEH
 OTH
VEH
 Passenger/Witness/Other
         
         
         

 TYPE  INTERVIEW  SECURE
   Full Investigation    Insured Vehicle Driver    Passengers    CHP/Police Report    Medical Authorization    Medical Reports
 Limited Investigation  Adverse Vehicle Driver  Passengers  Insured Vehicle Appraisal  Adverse Vehicle Appraisal  
   Witnesses    PHOTOGRAPH
   Insured Vehicle  Adverse Vehicle  Scene of Loss

 Special Instructions

 
 

Date of Assignment:

  
 

Due Date: