Tool/Equipment Loss Assignment Sheet

* Fields marked with an asterisk are required

Check one of the following: Licensed Insurance Carrier
Independent Adjusting Firm
*Claim Handler:
*Insurance Carrier:
Branch Affiliation (if applies):
*Phone (Office):
Phone (Mobile):
*Email:
*Email (verify):
Fax:
*Check one of the following: Attached is the insured's loss inventory
Please contact insured to obtain loss inventory
Attachments:
*Insured's Name:
*Claim Number:
Contact Name:
City, State:
Phone:
*Date of Loss:
*Check one of the following: Evaluate only: do not facilitate replacement at this time
Evaluate & replace: immediately contact insured to facilitate replacement
*Check one of the following: RCV coverage
ACV coverage
Policy Limit (coverage and/or per item):
Deductible Amount:
Check one of the following: Carrier to satisfy deductible w/insured (expedites replacement process)
RTF to collect deductible from insured
Special Instructions:
 
 
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