PROPERTY/CASUALTY
WORK REQUEST FORM
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Your Name Your E-mail Address
Assignment Date: Date of Loss :
Claim No: Policy No:

CLIENT INFORMATION

Company Name:
Contact:
Address:
City: State: Zip:
Phone: Fax: Cell No.:
E-mail Address:

OUTSIDE ADJUSTER / LAWYER FIRM INFORMATION

Company/Firm Name:
Contact:
Address:
City: State: Zip:
Phone: Fax: Cell No.:
E-mail Address:

INSURED's INFORMATION

Name:
Contact:
Address:
City: State: Zip:
Phone: Fax: Cell No.:
E-mail Address:

CLAIMANT's INFORMATION

Name:
Contact:
Address:
City: State: Zip:
Phone: Fax: Cell No.:
E-mail Address:

CLAIM LOCATION INFORMATION


Same as Insured's Address
Same as Claimant's Address
Other Address/Location

CLAIM INFORMATION

Type of Claim


Services Requested


Additional Information or Comments

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