Casualty Assignment Form
Please complete and submit the following information regarding your Casualty claim assignment or email your assignment to NewClaims@custard.com
Your assignment will be sent to our HOTLINE for immediate processing. Required fields are marked with *
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Location of Adjuster Assignment
Assignment City, State, and Country
Please Select
City
State / Province
USA
Country
Submitted By
First Name
Last Name
Contact Information
Phone Number*
Cell Phone Number
Email Address*
Fax Number
Company
Company Name*
Branch / Office Number
Address
Address Line 1*
Address Line 2
City*
ZIP / Postal Code*
Please Select
State / Province*
USA
Country*
Report To (if different from above)
First Name
Last Name
Cell Phone Number
Fax Number
Policy Information
mm/dd/yyyy
Policy Number
Policy Effective Date
Loss Information
Customer Claim Number
Brief Description of Loss*
mm/dd/yyyy
Date of Loss*
Location of Loss
Were Police Called?
Was Fire Dept. Called?
Name of Police Dept.
Insured Information
Insured Person / Company*
First Name
Last Name
Insured Address
Insured Address Line 1
Insured Address Line 2
Insured City
Insured ZIP / Postal Code
Please Select
Insured State / Province
USA
Insured Country
Contact Information
Insured Home Phone Number
Insured Cell Phone Number
Insured Email Address
Insured Work Phone Number
Injured Party
Injured Party First Name
Injured Party Last Name
Description of Injury(ies)
Claimant Information
Description of Injury(ies)
Injured Party First Name
Injured Party Phone Number
Injured Party Last Name
Injured Party Email Address
Witness Information
Witness First Name
Witness Last Name
Witness Address Line 1
Witness Address Line 2
Witness City
Witness ZIP / Postal Code
Please Select
Witness State / Province
USA
Witness Country
Witness Phone Number
Witness Cell Phone Number
Witness Email Address
Witness Work Phone Number
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Attach file(s) to this assignment
Action(s) to take / Special Instructions
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