::JBAIA NEW ASSIGNMENT::
New Assignment
* - required field(s)
 
 Date Assigned:
 Client/Adjuster:
 * Client's email:
 Client's Phone:
 Client's Claim Number:
 
 
Coverage Information
 
 Coverage Amounts: A.  B.  C.
D.  Other
 Deductible:
 Forms/Endorsement(s):
 Policy Number: Effective Date:(mm/dd/yyyy) 
 
Insured
 
 Name:
 Contact:
 Address:
 Phone:
 
Claimant
 
 Name:
 Contact:
 Address:
 Phone:
 
Loss Information
 
 Date of Loss:(mm/dd/yyyy)
 Location of Loss:
 Type of Loss:
 Description of Loss:
 Instructions:
 Attach File:
(max file size: 5MB)