Canadian Shield

A Higher Standard

Assignment Form

Property Assignment Form

Please complete and submit the following information regarding your property 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:

Policy Date:

Coverages:

Loss Information

Date of Loss:

Company Claim #:

Location of Loss:

Brief Description of Loss:

Were the Police called?:

Was the Fire Department called?:

Name of Police Department:

Claimant Information (If applicable)

Claimant First Name:

Claimant Last Name:

Claimant Address:

Claimant Address (Cont):

City:

Province:

Postal Code:

Claimant Home Phone:

Claimant Work Phone:

Actions to take/Special Instructions:

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