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Motor Vehicle Assignment Form
Please complete and submit the following information regarding your Motor Vehicle assignment

Your assignment will be sent to our HOTLINE

To submit an assignment to a different location, please select the location


NOTE: Fields marked with an asterisk (*) are required.

Location of Adjuster Assignment
City:
State:

Submitted By Contact Information
First Name:*
Last Name:*
Phone:*
Fax:*
EMail:*

Submitted By Company Information
CIA Customer #:
First Name:*
Last Name:*
Company Name:*
Street Address:*
Street Address (cont):
City:*
State / Province:*
Zip / Postal Code:*
Contact Phone:*
Contact Fax:*
Contact EMail:*

Policy Information
Policy Number:
Policy Effective Date:

Loss Information
Date of Loss:*  
Customer Claim #:
Location of Loss:
Brief Description of Loss:*
(limited to 70 lines of text)
Were Police Called?
Was a Ticket Issued?
Name of Police Dept.:

Insured Information
Insured Person / Company:*
Contact First Name:
Contact Last Name:
Insured Address:
Insured Address (cont):
City:
State / Province:
Zip / Postal Code:
Insured Home Phone:
Insured Work Phone:

Insured Vehicle Information
Vehicle Plate/Tag Number:
Vehicle Make:
Vehicle Model:
VIN:
Driver's First Name:
Driver's Last Name:
Driver's Home Phone:
Driver's Work Phone:
Damage Description:
Is Car Drivable?
If not, where is the vehicle?
Injured Party First Name:
Injured Party Last Name:
Description of Injury(ies):

Claimant Information
Claimant First Name:
Claimant Last Name:
Claimant Address:
Claimant Address (cont):
City:
State:
Zip / Postal Code:
Claimant Home Phone:
Claimant Work Phone:

Claimant Vehicle Information
Vehicle Plate / Tag Number:
Vehicle Make:
Vehicle Model:
VIN:
Driver's First Name:
Driver's Last Name:
Driver's Home Phone:
Driver's Work Phone
Damage Description:
Is Car Drivable?
If not, where is Vehicle?
Injured Party First Name:
Injured Party Last Name:
Description of Injury(ies):

Witness Information
Witness First Name:
Witness Last Name:
Witness Address:
Witness Address (cont):
City:
State / Province:
Zip / Postal Code:
Witness Home Phone:
Witness Work Phone:
Action(s) to take /
Special Instructions
(Limited to 70 lines of text)
Attach a file to this assignment
(cannot exceed 4 MB): 		 
Preferred Method of confirmation from CIA:
Please click the Submit button only once. It may take a few minutes for your claim to be processed. You will receive a confirmation once your assigment has been sent.



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