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Colonial Claims Service

CASUALTY ASSIGNMENT FORM

  • All required fields are marked with a red asterisk *
  • Please provide as much information as possible
  • Please attach claim documents in a separate email to
    frontdesk@colonialclaimsservice.com
    OR fax supports to 978-741-2343

Account Information *


Company:
Claim No:
Policy Number:
Adjuster/assignor name:
City:
Phone #:
Date of loss: MM/DD/YYYY
Address:
State: Zip code:
E-mail:
Type of loss *






Loss description and location *

Scope of assignment * Contact Instructions *
Recorded interview Written statement Interview
Insured
Claimant

Insured Information *



Name:
First: Last:
Address:
City: State: Zip code:
Phone #:

Additional Information

Claimant Information *



Name:
First: Last:
Address:
City: State: Zip code:
Phone #:

Additional Information

Additional Contacts

Claimant Witness Other
Name:
First: Last:
Address:
City: State: Zip code:
Phone #:

Additional Information

Documents and activities:
Please attach any supporting documents via email to frontdesk@colonialclaimsservice.com OR fax to 978-741-2343

Police Report Scene Photographs and Diagram
Medical Authorization Medical Records
Criminal History Asset Check
Activity Check  

Reporting Requirements: *

Initial Reporting:
Verbal 7 Days 21 Days 30 Days

Subsequent Reporting:
21 Days 30 Days Other