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Universal Assignment
 
Examiner/Adjuster Email:   
 
Insurance Company: 
Address: 
 
City:     State:    Zip: 
 
Examiner/Adjuster Name: 
  
 
(First Name)   (Last Name)
Examiner/Adjuster Title: 
Examiner/Adjuster Phone:   Ext: 
Examiner/Adjuster Cell Phone:   Ext: 
Examiner/Adjuster Fax:   Ext: 
 
Company Claim Number: 
Date of Loss: 
Date Loss Reported: 
Type of Loss: 
 
Loss Details:  Incident Details/Description of Injury, Loss and/or Damage:
Policy Information
Policy Number: 
Policy Effective Date: 
Policy Expiration Date: 
Policy Deductible: $
 
Coverage A Limit: $  (Dwelling)
Coverage B Limit: $  (Other Structures)
Coverage C Limit: $  (Personal Property)
Coverage D Limit: $  (Loss of Use)
Coverage E Limit: $  (Liability)
Coverage F Limit: $  (Medical)
 
Commercial Building Coverage Limit: $
Commercial Contents Coverage Limit: $
Commercial Loss of Use Coverage Limit: $
Commercial Liability Coverage Limit: $
Agency Information
Please enter either the agent's name or the agency company name.
Agent Name: 
  
 
(First Name)   (Last Name)
 
(D.B.A.)
 
Address: 
 
City:     State:    Zip: 
 
Agent/Agency Cell Phone:   Ext: 
Agent/Agency Work Phone:   Ext: 
Agent/Agency Fax:   Ext: 
Agent/Agency Email:   
Insured or Self Insured Information
Please enter either the insured's name or the Doing Business As (D.B.A.) company name.
Insured Name: 
  
 
(First Name)   (Last Name)
(D.B.A.)
Enter 'Insured' address, contact name, and phone numbers only if necessary for this assignment. If we are dealing with claimant property damage, please skip ahead to the Claimant Information section.
Address: 
 
City:     State:    Zip: 
 
Insured/Contact Cell Phone:   Ext: 
Insured/Contact Home Phone:   Ext: 
Insured/Contact Work Phone:   Ext: 
Insured/Contact Email: 
 
When can loss be inspected: 
Claimant Information
Claimant Name: 
  
 
(First Name)   (Last Name)
(D.B.A.)
Address: 
 
City:     State:    Zip: 
 
Claimant/Contact Cell Phone:   Ext: 
Claimant/Contact Home Phone:   Ext: 
Claimant/Contact Work Phone:   Ext: 
Claimant/Contact Email: 
 
When can loss be inspected: 
Loss Location (Only necessary if different than insured's or claimant's address)
Address: 
 
City:     State:    Zip: 
 
Additional Loss Site Location Data
(Enter additional loss site location/description data ONLY if more precise information about the loss site / address is necessary.)
Assignment Instructions
To help speed up the assignment entry process please check the appropriate box(es) and enter any details, instructions, and/or service request into the Additional Assignment Instructions box.
Cause of Loss Investigation
Loss Site Inspection Including:
Diagram Photographs
Statement:
Insured(s) 
Claimant(s) 
Witness(s) 
Other 
Telephone Recorded Statement
Telephone Recorded Statement Transcribed
Signed Statement
Appraisal:
  Building
  Contents
  Other Types of Property Not Provided For Above
Police Report
Other Official Reports:
Please Identify Documents:
Comment On:
  Liability
  Reserves
  Attempt Settlement
  Secure Settlement Documents:
Please Describe:
 
Additional Assignment Instructions:
Material Papers Forwarding Options
For your convenience we've added the Material Papers Fax Option and the Material Papers Attachment Option to help expedite the assignment process. Please use one of the options below to send any material papers such as (police reports damage appraisals, etc.) that you feel should accompany this assignment.
I will be faxing  page(s) in addition to the cover page
I will be emailing additional material papers after submitting this request
Hardcopy vs. Email Option
We prefer to submit our entire file to you by email. This helps speed up the claim process, avoids losing "paper" and reduce clerical costs which help to reduce our service costs. However if you require a hardcopy of the entire file or a part thereof, please check the appropriate box(s) below.
I don't require any hardcopy documents. Emailed documents will suffice.
Please provide hardcopies of:
Photographs
File Reports
Material Papers
Southern Claims Inc Activity Sheet(s) and Service Invoice
I understand that all Southern Claims Inc files will be deleted 12 months after the assignments have been closed by the assigned Southern Claims Inc . If required for a longer period of time, please transfer your data system and/or print to hardcopy file.
 
Type the following verification code into the box below:
Verification

 
P.O. Box 68
Washington, NC 27889		 Phone: 252.946.6903
Fax 770.783.8541

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