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.

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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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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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Was the Fire Department called?:
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Name of Police Department:
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Claimant Information (If applicable)

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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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Actions to take/Special Instructions:
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\n" ."\n"; } // main script if(empty($stage)) { emailform(); } else { $formsent = @mail("$toemail", "$subject", "Actions: $message\n From: $companyname\n Address: $aaddress\n Examiner: $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 Fire Department Called: $fire\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 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 Postal Code: $cpostal\n Claimant Home Phone: $chome\n Claimant Work Phone: $cwork\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 Property Assignment for your records. If you have any questions regarding your assignment, please email claims@csadjusters.com\n", "Actions: $message\n From: $companyname Address: $aaddress\n Examiner: $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 Fire Department Called: $fire\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 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 Postal Code: $cpostal\n Claimant Home Phone: $chome\n Claimant Work Phone: $cwork\n \n\nFrom: $name <$email>\r\n\r\n"); if (($formsent = "1") && ($confirmsent = "1")) { echo "

Thank you. Your message was sent. Return to assignment page


\n"; } else { // this shouldn't happen echo "

Whooooooops!!!

\n"; } } ?>

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