Liability Assignment | RVCS National Claims Adjusters

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Liability Assignment

Client Company:

Contact Name:

Company:
Phone Number:
E-mail:

Police/Authority Information

Authority Name:

Incident Report Number:

Authority Phone:

Please upload any reports here:

Special Instructions:

Loss Information

Claim Number:

Policy Number:

Date of Accident:

Time of accident:

Address:

State:

City:

Zip:

Description:

Was this claim previously reported?:

YesNo

Type of Liability?:

Vehicle AccidentCGLProduct LiabilityPremises Liability

Claimant Information

Contact Name:

Address:

State:

City:

Zip:

Claimant Phone:

Email:

Insured Information

Insured Name:

Address:

City:

State:

Zip:

Person to Contact:

Contact Phone:

Contact E-mail:

Preferred method/time to contact: