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New Assignment for CLOSED - Hammerman & Gainer, Inc.
Your Contact Information
First Name
Last Name
Company
Address
(Line 1)
(Line 2)
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State
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AE
AK
AL
AP
AR
AZ
BC
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MI
MN
MO
MS
MT
NB
NC
ND
NE
NF
NH
NJ
NM
NS
NT
NU
NV
NY
OH
OK
ON
OR
PA
PE
PR
QC
RI
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SD
SK
TN
TX
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ZIP
Phone:
eMail:
New Assignment Information
Your Claim #:
Assignment Instructions:
Characters left:
Insured's Information
Policy #:
Phone #:
Alternate Phone #:
Company:
First Name:
Last Name:
Street Address:
Address 2:
City:
State:
AA
AB
AE
AK
AL
AP
AR
AZ
BC
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MI
MN
MO
MS
MT
NB
NC
ND
NE
NF
NH
NJ
NM
NS
NT
NU
NV
NY
OH
OK
ON
OR
PA
PE
PR
QC
RI
SC
SD
SK
TN
TX
UT
VA
VT
WA
WI
WV
WY
YT
Zip:
Mortgagee:
Loss Location
Street Address:
Address 2:
City:
State:
AA
AB
AE
AK
AL
AP
AR
AZ
BC
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MI
MN
MO
MS
MT
NB
NC
ND
NE
NF
NH
NJ
NM
NS
NT
NU
NV
NY
OH
OK
ON
OR
PA
PE
PR
QC
RI
SC
SD
SK
TN
TX
UT
VA
VT
WA
WI
WV
WY
YT
Zip:
Claimant Information
(if applicable)
First Name:
Last Name:
Phone:
Street Address:
Address 2:
City:
State:
AA
AB
AE
AK
AL
AP
AR
AZ
BC
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MI
MN
MO
MS
MT
NB
NC
ND
NE
NF
NH
NJ
NM
NS
NT
NU
NV
NY
OH
OK
ON
OR
PA
PE
PR
QC
RI
SC
SD
SK
TN
TX
UT
VA
VT
WA
WI
WV
WY
YT
Zip:
Agent Information
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First Name:
Last Name:
Company:
Office Phone:
Cell Phone:
Street Address:
Address 2:
City:
State:
AA
AB
AE
AK
AL
AP
AR
AZ
BC
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MI
MN
MO
MS
MT
NB
NC
ND
NE
NF
NH
NJ
NM
NS
NT
NU
NV
NY
OH
OK
ON
OR
PA
PE
PR
QC
RI
SC
SD
SK
TN
TX
UT
VA
VT
WA
WI
WV
WY
YT
Zip:
Country:
Loss Information
Date of Loss:
Type of Loss:
Fire
Flood
Hail
Hurricane
Liability
Theft
Vandalism
Water
Wind
Workers' Compensation
Other
Unit:
Flood
Daily - Residential
Daily - Commercial
Liability- Personal
Liability- Commercial
CATASTROPHE
Auto
Other
Other
Other
Misc
Type of Adjustment:
Limited
Full
Loss Description:
Characters left:
VIN #:
Deductible:
Wind Deductible:
Coverage A
Building
Other Structures
Personal Property
Loss of Use / ALE
Business Personal Property
Business Income Interruption
Liability
*******************************
Appurtenant Unit Covered Damage
Appurtenant Unit Gross Loss RCV
Appurtenant Unit Gross Loss RCV
Building Covered Damage ACV
Building Gross Loss RCV
Building Property Value ACV
Building Property Value RCV
Building Removal Protection
Building Replacement Cost
Building Salvage
Contents Property Value Rcv
Contents Property Value Acv
Contents Gross Loss Rcv
Contents Covered Damage Acv
Contents Removal Protection
Contents Salvage
Coverage B
Building
Other Structures
Personal Property
Loss of Use / ALE
Business Personal Property
Business Income Interruption
Liability
*******************************
Appurtenant Unit Covered Damage
Appurtenant Unit Gross Loss RCV
Appurtenant Unit Gross Loss RCV
Building Covered Damage ACV
Building Gross Loss RCV
Building Property Value ACV
Building Property Value RCV
Building Removal Protection
Building Replacement Cost
Building Salvage
Contents Property Value Rcv
Contents Property Value Acv
Contents Gross Loss Rcv
Contents Covered Damage Acv
Contents Removal Protection
Contents Salvage
Coverage C
Building
Other Structures
Personal Property
Loss of Use / ALE
Business Personal Property
Business Income Interruption
Liability
*******************************
Appurtenant Unit Covered Damage
Appurtenant Unit Gross Loss RCV
Appurtenant Unit Gross Loss RCV
Building Covered Damage ACV
Building Gross Loss RCV
Building Property Value ACV
Building Property Value RCV
Building Removal Protection
Building Replacement Cost
Building Salvage
Contents Property Value Rcv
Contents Property Value Acv
Contents Gross Loss Rcv
Contents Covered Damage Acv
Contents Removal Protection
Contents Salvage
Coverage D
Building
Other Structures
Personal Property
Loss of Use / ALE
Business Personal Property
Business Income Interruption
Liability
*******************************
Appurtenant Unit Covered Damage
Appurtenant Unit Gross Loss RCV
Appurtenant Unit Gross Loss RCV
Building Covered Damage ACV
Building Gross Loss RCV
Building Property Value ACV
Building Property Value RCV
Building Removal Protection
Building Replacement Cost
Building Salvage
Contents Property Value Rcv
Contents Property Value Acv
Contents Gross Loss Rcv
Contents Covered Damage Acv
Contents Removal Protection
Contents Salvage
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