Casualty Claim Assignment Form
Use this form only for the following claim types:
  • Personal and Commercial Auto
  • Truck Claims
  • Construction Defect
  • General Liability
* = Required
*Name:
Today's Date:
*Company:
*Email:
Company Address:
*City:
State or Province:
Zip or Postal Code:
*Phone:
Fax:
Claim Number:
Effective Dates:
to
Date of Loss:
Time of Loss:
AM PM
Assignment Type
Choose Full Assignment or Task Assignment below.
FULL ASSIGNMENT
Please investigate and handle all exposures to conclusion.

Instructions:
TASK ASSIGNMENT
Please complete the following tasks:
Statements
Signed Statement
Recorded Statement by Phone
Recorded Statement in Person
 Named Insured
Insured Driver
Insured Passenger(s)
Witness(es)
Claimant(s)
Claimant Driver
Claimant Passenger(s)
Records / Reports / Documentation
Police Report
Fire Report
DMV Driver Records
DMV Vehicle Records
Other: 		Medical Authorization
Wage Authorization
Medical Records
Employer Wage Records
Scene / Photographs / Diagram
Scene Photos
Scene Diagram
Insured Vehicle Photos
 Claimant Vehicle(s) Photos
Claimant Photo
Canvass for Witnesses
Other Investigation
Insured Vehicle Appraisal
Insured Vehicle Appraisal
Insured Vehicle Appraisal
 Insured Vehicle Appraisal
Insured Vehicle Appraisal
Insured
Name:
 Residence Phone:
Address:
 Cell Phone:
City:
 Business Phone:
State/Province:
 Zip or Postal Code:
Person to Contact:
Facts
Location of Loss:
Description of Loss or Accident:
Policy Information
Bodily Injury:
 Property Damage:
Combined Single Limit:
 Medical Payments:
Comprehensive Deductible:
 Collision Deductible:
Other Deductibles:
 Loss Payee (indicate if none):
Insured Vehicle (if Auto Loss)
Vehicle Number:
 Year:
Make:
 Model:
Plate Number:
 VIN:
Owner's Name:
 Owner's Address:
State/Province:
 Zip or Postal Code:
Owner's Phone:
Driver's Name:
 Driver's Address:
State/Province:
 Zip or Postal Code:
Driver's Phone:
Relation to Insured:
 Driver's License Number:
Date of Birth:
Describe Damage:
Repair Estimate:
 Where can vehicle be seen?
When?
Claimant Property Damage
Description: (auto make and model)
 Other Vehicle or Property Insured?
Yes No
Company or Agency Name:
 Policy Number:
Owner/Claimant:
 Owner's Address:
Owner's State or Province:
 Driver's Name:
Is Driver same as Owner?
Yes No		 Driver's Phone:
Describe Damage:
Estimate Amount:
 Where can vehicle be seen?
More than one adverse vehicle?
Yes No
(If yes, please include information under "Further Information or Instructions" below)
Injured Parties (Insured or Claimant)
#1 Name:
 Phone:
Address:
 Age:
City:
 Pedestrian
Insured Vehicle
Adverse Vehicle
State/Province:
 Zip or Postal Code:
Type and Extent of Injury:
#2 Name:
 Phone:
Address:
 Age:
City:
 Pedestrian
Insured Vehicle
Adverse Vehicle
State/Province:
 Zip or Postal Code:
Type and Extent of Injury:
Additional Injured Parties?
Yes No
(If yes, please include information under "Further Information or Instructions" below)
Witnesses
#1 Name:
State/Province:
 Zip or Postal Code:
Address:
 Phone:
City:
#2 Name:
State/Province:
 Zip or Postal Code:
Address:
 Phone:
City:
Additional Witnesses?
Yes No
(If yes, please include information under "Further Information or Instructions" below)
Further Information or Instructions:
Security question (to prevent spam):



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Thank you for your report relative to the [client] matter. It is an excellent report and I appreciate it.
— Monticello Insurance


Additional Claim Forms:
HEAD OFFICE:
Sun Valley, California 91353
Mobile: (818) 581-6416
Office: (818) 908-1860
Fax: (818) 273-1045