Casualty Assignment Form

  • CLIENT INFORMATION

  • INSURED INFORMATION

  • What is the insured's Address:

  • LOSS INFORMATION

  • DAMAGE INFORMATION

  • What is the address of the injured party:

  • What is the address of the property owner:

  • WITNESSES

  • What is the witness's of the address:

  • POLICY INFORMATION

  • Please enter applicable coverage and limits:

  • Limits BI:

  • Limits PD:

  • Limits CSL:

  • OTHERS