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New Assignment for DSB Claims Solutions
Your Contact Information
First Name
Last Name
Company
Address
(Line 1)
(Line 2)
City
State
AA
AB
AE
AK
AL
AP
AR
AZ
BC
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MI
MN
MO
MS
MT
NB
NC
ND
NE
NF
NH
NJ
NM
NS
NU
NV
NY
OH
OK
ON
OR
PA
PE
PR
QC
RI
SC
SD
SK
TN
TX
UT
VA
VT
WA
WI
WV
WY
YT
ZIP
Phone:
eMail:
New Assignment Information
Your Claim #:
Assignment Instructions:
Characters left:
Insured's Information
Policy #:
Phone #:
Alternate Phone #:
Company:
First Name:
Last Name:
Street Address:
Address 2:
City:
State:
AA
AB
AE
AK
AL
AP
AR
AZ
BC
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MI
MN
MO
MS
MT
NB
NC
ND
NE
NF
NH
NJ
NM
NS
NU
NV
NY
OH
OK
ON
OR
PA
PE
PR
QC
RI
SC
SD
SK
TN
TX
UT
VA
VT
WA
WI
WV
WY
YT
Zip:
Mortgagee:
Loss Location
Street Address:
Address 2:
City:
State:
AA
AB
AE
AK
AL
AP
AR
AZ
BC
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MI
MN
MO
MS
MT
NB
NC
ND
NE
NF
NH
NJ
NM
NS
NU
NV
NY
OH
OK
ON
OR
PA
PE
PR
QC
RI
SC
SD
SK
TN
TX
UT
VA
VT
WA
WI
WV
WY
YT
Zip:
Claimant Information
(if applicable)
First Name:
Last Name:
Phone:
Street Address:
Address 2:
City:
State:
AA
AB
AE
AK
AL
AP
AR
AZ
BC
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MI
MN
MO
MS
MT
NB
NC
ND
NE
NF
NH
NJ
NM
NS
NU
NV
NY
OH
OK
ON
OR
PA
PE
PR
QC
RI
SC
SD
SK
TN
TX
UT
VA
VT
WA
WI
WV
WY
YT
Zip:
Agent Information
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First Name:
Last Name:
Company:
Office Phone:
Cell Phone:
Street Address:
Address 2:
City:
State:
AA
AB
AE
AK
AL
AP
AR
AZ
BC
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MI
MN
MO
MS
MT
NB
NC
ND
NE
NF
NH
NJ
NM
NS
NU
NV
NY
OH
OK
ON
OR
PA
PE
PR
QC
RI
SC
SD
SK
TN
TX
UT
VA
VT
WA
WI
WV
WY
YT
Zip:
Country:
Loss Information
Date of Loss:
Type of Loss:
Water
Wind
Fire
Smoke
Sewer Backup
Hail
Burglary
Break & Enter
Theft
Lightening
Vehicle Impact
Other
Motor Vehicle Accident
Watercraft
Slip/Trip/Fall
Collapse/Impact
TP Property Liability
Bodily Injury Liability
Unit:
Residential Property
Commercial Property
Industrial Property
Automobile
Marine
Broker Administration
Liability
Type of Adjustment:
Limited
Full
Loss Description:
Characters left:
VIN #:
Deductible:
Wind Deductible:
Coverage A
Building
Business Personal Property
Contents
ALE
Detached Private Structures
Condominium Improvements\Betterments
Industrial Hygenist
Adjusting Fee
Condo Loss Assessment
Forensic Accountant
Forensic Engineer
Fair Rental Value
Auto Physical Damage
Auto Appraisal
Coverage B
Building
Business Personal Property
Contents
ALE
Detached Private Structures
Condominium Improvements\Betterments
Industrial Hygenist
Adjusting Fee
Condo Loss Assessment
Forensic Accountant
Forensic Engineer
Fair Rental Value
Auto Physical Damage
Auto Appraisal
Coverage C
Building
Business Personal Property
Contents
ALE
Detached Private Structures
Condominium Improvements\Betterments
Industrial Hygenist
Adjusting Fee
Condo Loss Assessment
Forensic Accountant
Forensic Engineer
Fair Rental Value
Auto Physical Damage
Auto Appraisal
Coverage D
Building
Business Personal Property
Contents
ALE
Detached Private Structures
Condominium Improvements\Betterments
Industrial Hygenist
Adjusting Fee
Condo Loss Assessment
Forensic Accountant
Forensic Engineer
Fair Rental Value
Auto Physical Damage
Auto Appraisal
Endorsements:
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