ASSIGNMENT
FORM
DATE FAXED: ___/___/_____
INSURANCE
COMPANY:___________________________________________
ADJUSTER:
__________________________PHONE:
_________________________________
ADDRESS:
_____________________________________________________________________
CITY: _________________STATE: ________ZIP:
______________FAX:__________________
DATE OF LOSS:_____/_____/________
TYPE OF POLICY - ACV or REPLACEMENT
COST:______________________________
YOUR CLAIM OR REFERENCE
NUMBER:_______________________________________
INSURED'S
or CLAIMANT'S NAME:
___________________________________________
WORK
PHONE:
_____________________HOMEPHONE:___________________________
ADDRESS:
____________________________________________________________________
CITY:
______________________ STATE:
_________________________ZIP:____________
VESSEL
MAKE and YEAR:
_________________________________LENGTH:___________
ENGINEMAKE,
HORSEPOWER and
YEAR:_____________________________________
VESSEL
LOCATION_____________________________________________________________
CONTACT
PERSON:
____________________________________________________________
PHONE NO:_______________________
TYPE OF LOSS OR WORK NEEDED:
Theft:
Grounding: ______ Engine/Drive Damage: ______
Lightning Strike: ______
Partial/Total
Submersion: ____________Survey: ____________Fire:
_____________
Striking Submerged Object:________Demasting: _________
Other: _____________
_______________________________________________________________________________
DESCRIPTION
OF LOSS (if available) and SPECIAL INSTRUCTIONS:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
COVERAGE:
HULL:
__________ENGINE: ___________PERSONAL
PROPERTY:____________________
TRAILER:_________EMERGENCY
SERVICES:____________MEDICAL:_______________
DEDUCTIBLES:________________________________________________________________
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