ASSIGNMENT FORM     Customer identification Report language: French English File number: Customer name: Adjuster: E-mail address: Details of loss Building Equipment Type of event: Choose event: Arbitrage Arbre Cambriolage - Vol Dynamitage Eau Effondrement Explosion Exposition à un incendie Foudre Fumée Grèle - Neige - Glace Huile Impact - Collision Incendie Inondation Litige Refoulement d'égoût Responsabilité Vandalisme Vent Autre 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 Building replacement value: Yes   Replacement cost of all goods and damages: Yes Building depreciation: Yes   OR   Work depreciation: Yes   Damages only: Yes Tenant 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

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