Canadian Shield

A Higher Standard

Assignment Form

Casualty Assignment Form

Please complete and submit the following information regarding your casualty assignment.

For faster processing, please submit as much information as possible.

Contact Information

Company Name:

Address:

Examiner Name:

Phone:

Fax (Optional):

Email:

Insured Information

Insured Person/Company:

Contact First Name:

Contact Last Name:

Insured Address:

Insured Address (Cont):

City:

Province:

Postal Code:

Insured Home Phone:

Insured Work Phone:

Policy Information

Policy Number:

Coverages:

Policy Date:

Loss Information

Date of Loss:

Customer Claim #:

Location of Loss:

Brief Description of Loss:

Were the Police called?:

Was the Fire Department called?:

Name of Police Department:

Claimant Information

Claimant First Name:

Claimant Last Name:

Claimant Address:

Claimant Address (Cont):

City:

Province:

Postal Code:

Claimant Home Phone:

Claimant Work Phone:

Injured Party First Name:

Injured Party Last Name:

Description of Injury(ies):

Witness Information

Witness First Name:

Witness Last Name:

Witness Address:

Witness Address (Cont):

City:

Province:

Postal Code:

Witness Home Phone:

Witness Work Phone:

Actions to take/Special Instructions:

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