Canadian Shield

A Higher Standard

Assignment Form

Motor Vehicle Assignment Form

Please complete and submit the following information regarding your motor vehicle 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:

Insured Vehicle Information

Vehicle Plate #:

Vehicle Make:

Vehicle Model:

Vehicle VIN:

Driver's First Name:

Driver's Last Name:

Driver's Home Phone:

Driver's Work Phone:

Damage Description:

Is car driveable:

If not, where is the vehicle:

Injured Party First Name:

Injured Party Last Name:

Description of Injury(ies):

Claimant Vehicle Information

Claimant First Name:

Claimant Last Name:

Claimant Address:

Claimant Address (Cont):

City:

Province:

Postal Code:

Claimant Home Phone:

Claimant Work Phone:

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:

Policy Information

Policy Number:

Policy Date:

Coverages:

Loss Information

Date of Loss:

Company Claim #:

Location of Loss:

Brief Description of Loss:

Were the Police called?:

Was a ticket issued?:

Name of Police Department:

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