You MUST have cookies enabled in order for your submission to be successful.

New Assignment for Daniel J. Hannon & Associates
Your Contact Information
First Name
Last Name
Company
Address (Line 1)
(Line 2)
City
State
ZIP
Phone:
eMail:
New Assignment Information
Your Claim #:
Assignment / Budget:
Characters left:
Insured's Information
Company:
First Name:
Last Name:
Street Address:
Address 2:
City:
State:
Zip:
Phone #:
Alternate Phone #:
Loss Location
Street Address:
Address 2:
City:
State:
Zip:
Claimant Information (if applicable)
First Name:
Last Name:
Date of Birth:
SS#:
Home Phone:
Cell Phone:
Work Phone:
Email:
Street Address:
Address 2:
City:
State:
Zip:
Occupation:
Injury:
Characters left:
Claimant Physical Description
Height:
Weight:
Eye Color:
Hair Color:
Agent Information Show | Hide
Loss Information
Date of Loss:
Type of Loss:
Unit:
Type of Adjustment:
Upload Document(s) to the Claim
Select Files
Description (Additional File)