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New Assignment for Davies
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Your Claim #:
Assignment Instructions:
Characters left:
Insured's Information
Policy #:
Phone #:
Alternate Phone #:
Company:
First Name:
Last Name:
Street Address:
Address 2:
City:
State:
AA
AB
AE
AK
AL
AP
AR
AZ
BC
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MI
MN
MO
MS
MT
NB
NC
ND
NE
NF
NH
NJ
NM
NS
NV
NY
OH
OK
ON
OR
PA
PR
QC
RI
SC
SD
SK
TN
TX
UT
VA
VT
WA
WI
WV
WY
YT
Zip:
Mortgagee:
Loss Location
Street Address:
Address 2:
City:
State:
AA
AB
AE
AK
AL
AP
AR
AZ
BC
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MI
MN
MO
MS
MT
NB
NC
ND
NE
NF
NH
NJ
NM
NS
NV
NY
OH
OK
ON
OR
PA
PR
QC
RI
SC
SD
SK
TN
TX
UT
VA
VT
WA
WI
WV
WY
YT
Zip:
Claimant Information
(if applicable)
First Name:
Last Name:
Phone:
Street Address:
Address 2:
City:
State:
AA
AB
AE
AK
AL
AP
AR
AZ
BC
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MI
MN
MO
MS
MT
NB
NC
ND
NE
NF
NH
NJ
NM
NS
NV
NY
OH
OK
ON
OR
PA
PR
QC
RI
SC
SD
SK
TN
TX
UT
VA
VT
WA
WI
WV
WY
YT
Zip:
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First Name:
Last Name:
Company:
Office Phone:
Cell Phone:
Street Address:
Address 2:
City:
State:
AA
AB
AE
AK
AL
AP
AR
AZ
BC
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MI
MN
MO
MS
MT
NB
NC
ND
NE
NF
NH
NJ
NM
NS
NV
NY
OH
OK
ON
OR
PA
PR
QC
RI
SC
SD
SK
TN
TX
UT
VA
VT
WA
WI
WV
WY
YT
Zip:
Country:
Loss Information
Date of Loss:
Type of Loss:
Accidental Discharge
Animal
Robbery
Assessment
Automobile
Sewer or Drain Back Up
Bodily Injury
Business Income
Casualty
Cat/Earthquake Auto
Cat/Earthquake Casualty
Cat/Earthquake Property
Catastrophe Property
Collapse
Commercial Automobile Cargo Loss
COVID-19
Equipment Failure
Event Day Services
Felled Tree
Fire - Commercial Building
Fire
Fire - Dwelling
Flood
Flood, Surface Water
Flood, Tidal Surge
Freeze
Frozen Pipe
Hail
Hurricane Delta
Hurricane Dorian
Hurricane Florence
Hurricane Harvey
Hurricane Henri
Hurricane Hermine
Hurricane IDA
Hurricane Irma
Hurricane Laura
Hurricane Matthew
Hurricane Michael
Hurricane Sally
Hurricane Zeta
Inland Marine
Jewelry Survey
Liability
Lightning
Medical Payments
Mechanical Breakdown
Mysterious Disappearance
Named Storm
Personal Injury
Pipe Break
Power Outage
Power Surge
PRE TRIAL HEARING-MEDIATION
Product Liability
Property
Property Damage
Sewage
Sinkhole
Smoke
Sump Pump Failure
Surface Water
Theft
Tornado
Tropical Storm Elsa
Tropical Storm ETA
Tropical Storm Henri
Tropical Storm Imelda
Tropical Storm Isaias
Vandalism
Vehicular
Vermin
Water Damage
Weight of Ice and/or Snow
Wind
Wind Driven Rain
Tropical Storm Nicholas
Workers' Compensation
Hurricane Ian
Hurricane/ Tropical Storm Nicole
Hurricane Idalia
Hurricane Debby
Tropical Storm Debby
Hurricane Francine
Hurricane Helene
Hurricane Milton
Unit:
Residential Property
Residential Liability
Commercial Property
Commercial Liability
Commercial Auto
Personal Auto
Workers Compensation
Fast Track Adjustment
Type of Adjustment:
Limited
Full
Time and Expense
Flat Rate
Daily Rate
Loss Description:
Characters left:
VIN #:
Deductible:
Wind Deductible:
Coverage A
Building 1
Contents
Bodily Injury
Property Damage
Coverage B
Building 1
Contents
Bodily Injury
Property Damage
Coverage C
Building 1
Contents
Bodily Injury
Property Damage
Coverage D
Building 1
Contents
Bodily Injury
Property Damage
Endorsements:
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