ASSIGNMENT FORM
   
Customer identification
Report language: French English File number:
Customer name:
Adjuster: E-mail address:
Details of loss Building Equipment
Type of event: Date of loss:
Comments:
Name of insured:
Event address:
Contact 1: Tel: Cell:
Contact 2: Tel: Cell:
Liability
Third party name:
Third party address:
Contact 1: Tel: Cell:
Contact 2: Tel: Cell:
Identification of insurers
Main insurer: %
File number: Policy number:
Insurer 2: %
Insurer 3: %
Insurer 4: %
Insurer 5: %
Others:
Insurance limit: Franchise:
Mandate specifications: BUILDING   Mandate specifications: EQUIPMENT
Reconstruction cost: Yes   Replacement cost of all goods and damages: Yes
Building depreciation: Yes   OR  
Work depreciation: Yes   Damages only: Yes
Tennant improvements: Yes   OR  
Thermography service: Yes   Summary appraisal only: Yes
Photos required: Yes      
 
DON'T FORGET TO PRINT A COPY FOR YOUR FILES PRIOR TO SENDING THE FORM