Online Assignment Submission Form

You can submit your assignments online using our form below:

You can also send assignments to assignments@churchill-claims.com or by fax to 866-800-0668.

Please call us at 877-840-6277 concerning any questions about sending assignments or our services.

Select the type of claim assignment:
- Casualty
- Property Loss
- Vehicle Appraisal
- Other
Please contact us with any questions you may have.
Year
Make
Model
VIN #
Vehicle Location & Address
Deductible Amount
Is ACV Required if Total Loss?
- Yes
- No
Actual Cash Value
Description of Assignment:
Are Recorded Statements Required?
Insured*
- Yes
- No
- See Notes
If Yes:*
- Recorded
- Unrecorded
Claimant*
- Yes
- No
- See Notes
If Yes:*
- Recorded
- Unrecorded
Witness*
- Yes
- No
- See Notes
If Yes:*
- Recorded
- Unrecorded
Statement Notes
Upload Document:
Drop files here or

Accepted file types: pdf, doc, docx, xls, xlsx, txt, rtf, jpg, jpeg, bmp, png, Max. file size: 15 MB, Max. files: 10.
Date of Loss
MM slash DD slash YYYY
Location of Loss:
Facts of Loss:
Claim Number:
Insured's Information
Insured's Name:

Name
Phone Number
Phone Number
Street Address

Street Address
Address Line 2

Address Line 2
City

City
State

State
Zip Code

Zip Code
Email

Email
Claimant's Information
Claimant's Name:

Name
Phone Number
Phone Number
Street Address

Street Address
Address Line 2

Address Line 2
City

City
State

State
Zip Code

Zip Code
Email

Email
Assignment Notes:
Your Name:*
Phone Number:*
Email:*
Enter Email Confirm Email
Insurance Company:*
Company Address:
Street Address Address Line 2 City State Zip Code
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Please call (877) 840-6277 or email info@churchill-claims.com with any questions about our services.