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HOME
Services
Workers’ Compensation
Trial Preparation
Property
Surveillance & SIU
Assignment Submissions
Contact Us
Pay Now
Assignment Submission
Please fill out the form below and our office will get back to you shortly. Thank You!
Assignment Submission Type:
(Required)
Select your Assignment Submission
Casualty / Workers' Compensation
Trial Preparation
Surveillance
Property
Today's Date
(Required)
MM slash DD slash YYYY
Examiner's Name
(Required)
First
Last
Examiner's Email Address
(Required)
Examiner's Phone Number
(Required)
Examiner's Fax Number
Carrier's Name
(Required)
Carrier's Address
(Required)
Street Address
City
State
Zip Code
Claim Information:
Claim Number
(Required)
Date of Loss
(Required)
MM slash DD slash YYYY
Policy Number
Claimant / Plaintiff Information:
Name
(Required)
First
Last
Address
(Required)
Street Address
City
State
Zip Code
Phone Number
(Required)
Date of Birth
MM slash DD slash YYYY
Social Security Number
Insured / Defendant Information:
Named Insured
Contact
Phone Number
Address
Street Address
City
State
Zip Code
Location of Loss
Insured Information:
Named Insured
Contact
Phone Number
Address
Street Address
City
State
Zip Code
Location of Loss
Casualty / Workers' Compensation Assignment:
Select Type(s) of Service(s)
Full Liability Investigation
Signed Statement(s)
Scene Photos/Diagram
Obtain Police/Accident Report
Alive and Well Check
Legal Firm Information:
Firm Name
(Required)
Address
(Required)
Street Address
City
State
Zip Code
Attorney Name
(Required)
Email
(Required)
Phone Number
Fax Number
Legal Matter Number / File Number
Trial Preparation Assignment:
Select Type(s) of Service(s)
Full Trial Preparation Services
Medical Expert Scheduling
Litigation Search
Criminal Search
Subpoena Preparation and Service
Property Assignment:
Select Type(s) of Service(s)
First Party Adjustment
First Party Appraisal
Property Damage/Liability Investigation
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Due Date
MM slash DD slash YYYY
Instructions
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