Continental Loss Adjusters

	Assign a Claim

Please fill all applicable fields. For Non applicable fields, simply put NA in the box.



Insurer:	Insurer’s address:	Type of Occurrence:
Assigning Person, & Phone #	Company Address:	Time of Occurrence:
Email Address	Company Phone:	Co-Insurers involved & percentage:
Insured:	Company Fax:	Policy #:
Insured's Address:	Report To:	Claim #:
Insured's Phone:	Date of Loss:	Surveillance:
Broker(s) handling Claim:	Place of Loss:	Photos:
Broker's Address:	Video:	Diagram:
Broker's Phone #:	Loss Estimate:	Full:
Broker's Fax Number:	F/R	Appraisal:
Broker's contact Person:	P/R
Insured Statement:
T/P Statement
Witness Statement:
What Happened:
What Would You Like Us to Do:
Special Instructions:
Other:
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