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.

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Contact Information

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Company Name:
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Address:
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Examiner Name:
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Phone:
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Fax (Optional):
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Email:
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Insured Information

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Insured Person/Company:
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Contact First Name:
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Contact Last Name:
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Insured Address:
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Insured Address (Cont):
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City:
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Province:
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Postal Code:
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Insured Home Phone:
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Insured Work Phone:
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Insured Vehicle Information

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Vehicle Plate #:
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Vehicle Make:
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Vehicle Model:
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Vehicle VIN:
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Driver's First Name:
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Driver's Last Name:
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Driver's Home Phone:
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Driver's Work Phone:
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Damage Description:
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Is car driveable:
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If not, where is the vehicle:
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Injured Party First Name:
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Injured Party Last Name:
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Description of Injury(ies):
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Claimant Vehicle Information

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Claimant First Name:
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Claimant Last Name:
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Claimant Address:
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Claimant Address (Cont):
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City:
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Province:
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Postal Code:
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Claimant Home Phone:
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Claimant Work Phone:
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Witness Information

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Witness First Name:
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Witness Last Name:
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Witness Address:
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Witness Address (Cont):
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City:
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Province:
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Postal Code:
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Witness Home Phone:
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Witness Work Phone:
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Actions to take/Special Instructions:
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Policy Information

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Policy Number:
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Policy Date:
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Coverages:
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Loss Information

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Date of Loss:
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Company Claim #:
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Location of Loss:
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Brief Description of Loss:
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Were the Police called?:
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Was a ticket issued?:
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Name of Police Department:
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\n" ."\n"; } if(empty($stage)) { emailform(); } else { $formsent = @mail("$toemail", "$subject", "Actions: $message\n Company name: $companyname\n Address: $aaddress\n Examiner Name: $lastname\n Phone: $phone\n Fax: $fax\n Policy Date: $pdate\n Policy Number: $pnum\n Coverages: $coverages\n Date of Loss: $ldate\n Customer Claim #: $lclaim\n Location of Loss: $location\n Brief Description: $description\n Police called: $police\n Ticket Issued: $ticket\n Police Department: $dept\n Insured Person/Company: $ip\n Contact First Name: $iname\n Contact Last Name: $ilast\n Insured Address: $iaddress\n Insured Address (Cont): $iaddress2\n City: $icity\n Province: $iprovince\n Postal Code: $ipostal\n Insured Home Phone: $iphone\n Insured Work Phone: $iwork\n Vehicle Plate: $vplate\n Vehicle Make: $vmake\n Vehicle Model: $vmodel\n Vehicle VIN: $vvin\n Drivers First Name: $driversname\n Drivers Last Name: $driverslast\n Drivers Home Phone: $drivershome\n Drivers Work Phone: $driverswork\n Damage Description: $damage\n Is car driveable: $driveable\n If not, where is vehicle: $where\n Injured party first name: $injuredname\n Injured part last name: $injuredlast\n Description of Injury(ies): $injuries\n Claimant First Name: $cname\n Claimant Last Name: $clast\n Claimant Address: $caddress\n Claimant Address (Cont): $caddress2\n City: $ccity\n Province: $cprovince\n Claimant Home Phone: $chome\n Claimant Work Phone: $cwork\n Witness First Name: $wname\n Witness Last Name: $wlast\n Witness Address: $waddress\n Witness Address (Cont): $waddress2\n City: $wcity\n Province: $wprovince\n Postal Code: $wpostal\n Witness Home Phone: $wphone\n Witness Work Phone: $wwork\n \n\nFrom: $name <$email>\r\n\r\n"); $confirmsent = @mail("$toemail2", "$subject2", "Above is the information from www.csadjusters.com. Keep this copy of your Motor Vehicle Assignment for your records. If you have any questions regarding your assignment, please email claims@csadjusters.com\n", "Actions: $message\n Company name: $companyname\n Address: $aaddress\n Examiner Name: $lastname\n Phone: $phone\n Fax: $fax\n Policy Date: $pdate\n Policy Number: $pnum\n Coverages: $coverages\n Date of Loss: $ldate\n Customer Claim #: $lclaim\n Location of Loss: $location\n Brief Description: $description\n Police called: $police\n Ticket Issued: $ticket\n Police Department: $dept\n Insured Person/Company: $ip\n Contact First Name: $iname\n Contact Last Name: $ilast\n Insured Address: $iaddress\n Insured Address (Cont): $iaddress2\n City: $icity\n Province: $iprovince\n Postal Code: $ipostal\n Insured Home Phone: $iphone\n Insured Work Phone: $iwork\n Vehicle Plate: $vplate\n Vehicle Make: $vmake\n Vehicle Model: $vmodel\n Vehicle VIN: $vvin\n Drivers First Name: $driversname\n Drivers Last Name: $driverslast\n Drivers Home Phone: $drivershome\n Drivers Work Phone: $driverswork\n Damage Description: $damage\n Is car driveable: $driveable\n If not, where is vehicle: $where\n Injured party first name: $injuredname\n Injured part last name: $injuredlast\n Description of Injury(ies): $injuries\n Claimant First Name: $cname\n Claimant Last Name: $clast\n Claimant Address: $caddress\n Claimant Address (Cont): $caddress2\n City: $ccity\n Province: $cprovince\n Claimant Home Phone: $chome\n Claimant Work Phone: $cwork\n Witness First Name: $wname\n Witness Last Name: $wlast\n Witness Address: $waddress\n Witness Address (Cont): $waddress2\n City: $wcity\n Province: $wprovince\n Postal Code: $wpostal\n Witness Home Phone: $wphone\n Witness Work Phone: $wwork\n \n\nFrom: $name <$email>\r\n\r\n"); if (($formsent = "1") && ($confirmsent = "1")) { echo "

Thank you. Your message was sent. Please check your email to confirm it was sent. Return to assignment page


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Whooooooops!!!

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