If you are an existing client, just mark the first box below and give us your name and state in the second as we have your contact information on file. THANK YOU FOR THE ASSIGNMENT! Existing Client? Existing client name and state Company Name Adjuster Claim number Address Line 1 City State Zip Code Daytime Phone () - Fax () - E-mail Address Insured Insured address Inusred contact Insured Number () - Loss location Type of loss Vehicles / equipment involved Other insured information Claimant # 1 Claimant address Claimant contact number () - Other numbers () - Second claimant Second Claimant Contact information Other claim information