Field Investigation Assignment

Company Information
Company Name
Assigning Adjuster
Assigning Adjuster's E-mail
Assigning Adjuster's Fax
Company Address
Street
  City State Zip
Company Phone Number 
Claim Number
Date of Accident

Information about Insured
Insured Name
Insured Address
Street
  City State Zip
Insured Phone
 Insured Cell Number
Contact Person
Policy Number (optional)

Brief description of occurrence:

Information about Claimant
Name
Address
Street
  City  State Zip
Phone Number
Cell Phone Number
If additional claimants,
 enter information here

Location of Accident: 

Services Requested / Instructions:

Do you want a report e-mailed to you in advance of the original? 

 Yes No

 

RC Clicks & Associates, Inc.
11125 Park Blvd., Suite 104-119
Seminole, Florida 33772
 Phone (727) 394-0907  · Fax (727)397-9243  
Home  ·  E-Mail: rcclicks@knology.net