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New Assignmentmh-admin2020-10-08T18:25:58+00:00

To submit an assignment electronically, please complete the following form.

An origin & cause expert will reply promptly.

Step 1 of 5 - Assignment Submitted By

Assignment Submitted By
Name*
Company Name
Email*
Cell Phone
Office Phone*
Ext.
Fax
Claim Number
Address
Street Address Address Line 2 City State ZIP Code
Confirmed Assignment By
Is the Billing information different than from Submitted by?*
- Yes
- No
Bill To (complete if different from above)
Billing Company
Billing Address
Street Address Address Line 2 City State ZIP Code
Billing Phone
Ext.
Billing Fax
Billing Email

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Location of Loss
Address of Loss*
Street Address Address Line 2 City State ZIP Code
Date of Loss
Date Format: MM slash DD slash YYYY
Time of Loss

: HH

MM

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Insured / Subject
Name of Insured / Subject
Phone
Ext.
Contact
Contact Phone
Ext.
Claimant Contact
Claimant Contact Phone
Ext
Is address different from location of loss
- No
- Yes
Address
Street Address Address Line 2 City State ZIP Code

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Additional Loss Information
Type of Loss
Type of Property
Occupancy
Insurance Coverage
Building $
Contents $
Other $
Vehicle Information (If Applicable)
Manufacturer
Year
Vehicle Location
Model
VIN
Color
Adjuster
Name
Phone
Ext.
Civil Authority Investigating
Agency
Contact
Phone
Ext.

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Instructions or Comments
Comments
File Attachments
Drop files here or

Accepted file types: doc, docx, pdf, jpg, gif, png.
Comments
This field is for validation purposes and should be left unchanged.

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