Property Claim Assignment Form
Use this form for Residential and Commercial Property Losses
* = Required
*Name:
Today's Date:
*Company:
*Email:
Company Address:
*City:
State or Province:
Zip or Postal Code:
*Phone:
Fax:
Policy Number:
Effective Dates:
to
Claim Number:
 Date of Loss:
Time of Loss:
AM PM
Insured
Name:
 Residence Phone:
Address:
 Person to Contact:
City:
 Business Phone:
State or Province:
 Zip or Postal Code:
Contact Phone:
Claimant
Name:
 Residence Phone:
Address:
 Person to Contact:
City:
 Business Phone:
State or Province:
 Zip or Postal Code:
Contact Phone:
Facts
Location of Loss:
Description of Loss:
Policy Information
Applicable Limits:
 Deductible:
Policy Forms/Endorsements:
Full Assignment
Special Instructions:
Limited Assignment
Non Waiver
Coverage Investigation
Official Reports
Photos
Determine Cause and Origin
Prepare Scope / Estimate
Obtain Statements from
ACV / RCV Evaluation
Diagram
Agreed Price
Investigate Subrogation
Dispose of Salvage
Other
Further Information or Instructions:
Security question (to prevent spam):



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You always provide excellent reports.
— Monticello Insurance


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