ASSIGNOR, ADJUSTER, and/or CARRIER INFORMATION
Current Date
Claim Number
Insurance Company
Adjuster / Assignor
Extension
Date of Loss
Deductible
VEHICLE INSPECTION INFORMATION
Year
Make
Model
Color
License
VIN
Primary Damage
Left Front
Front End
Right Front
Left Side
Right Side
Left Rear
Rear End
Right Rear
Roof
UnderCarriage
Vandalism
Fire
Flood
Other
Secondary Damage
Left Front
Front End
Right Front
Left Side
Right Side
Left Rear
Rear End
Right Rear
Roof
UnderCarriage
Vandalism
Fire
Flood
Other
Prior Damage
Left Front
Front End
Right Front
Left Side
Right Side
Left Rear
Rear End
Right Rear
Roof
UnderCarriage
Vandalism
Fire
Flood
Other
Other Damages
Multiple damage areas can be selected by using the "CTRL".
VEHICLE OWNER INFORMATION
Insured Name
Driver Name
Claimant Name
Vehicle Owner Address
City
State
Zip
Home Phone
Work Phone
Ext.
Other Phone
ASSIGNMENT INSTRUCTIONS
Special instructions / Location
Requested Services
Use "CTRL' to make multiple selections
Estimate, Report, & Photos
Low Speed Impact Inspection (Additional Photos)
Heavy Equipment Inspection & Appraisal
Off- Highway Vehicle Inspection (RV's, Quads, Duen Buggies, Campers, Trailers, Etc.)
Photo Only Assignment (Photos & Details of findings)
CDR - Crash Data Recovery
Accident Scene Investigation (Diagram, Map, Photos, & Report)
Property Damage Inspection (Fire, Flood, Auto vs. Property, Etc.)
Recorded Statement (Specify if transcribing is needed in instructions above)
Marine Equipment Appraisal
Other (specify in instructions above)
RESPONSE & CONFIRMATION
Select the type of response you require...
E-Mail
Phone Call
Written
If E-Mail response was chosen, please enter E-Mail address
CCS HomePage
Online Assignment Sheet
Services Offered
Contact Information
CDR
Links