For Insurance Professionals Only

Allen Dahle & Co., Inc. • ADC • CASUALTY LOSS

Direct Assign: CASUALTY LOSS

Kindly provide as much information as possible. * indicates required fields.
If you do not have the information for a * required field, please enter "unknown"

Your form message has been successfully sent.

You have entered the following data:

CASUALTY ASSIGNMENT FORM

Please correct your input in the following fields:

Error while sending the form. Please try again later.

YOUR First & Last Name as our Client {To Whom We Will Be Reporting} *

Company Name & Full Mailing Address *

YOUR First & Last Name & Your Contact Phone # *

E-mail address: *

DOL { mm/dd/yyyy} ▬ *

YOUR CLAIM | FILE # ▬ *

POLICY # ▬ *

Description of Loss ▬ *

General Assignment Instructions ▬ *

GENERAL LIABILITY

LIMITED ASSIGNMENT

FULL ASSIGNMENT

RECORDED STATEMENT

WRITTEN STATEMENT

INSUREDs Name, Full Mailing Address + Phone/s # ► *

Instructions Regarding Insured ► *

CLAIMANT Name, Full Mailing Address + Phone/s # ◘ *

Instructions/Other Info Regarding The Primary Claimant ◘ *

Are There Additional Claimants/Other Parties Involved? Please List Details ◘◘

Captcha (spam protection code) *

Note: Fields marked with * are required

INSURANCE PROFESSIONALS, PLEASE NOTE...

If your assignment has additional documents necessary for our handling adjuster to be aware of
- PLEASE - forward same as attachments to a separate email*. Your email body/cover must list pertinent assignment details, your contact information, a Subject Line indicating YOUR claim# and Named Insured. Following the above facilitates the immediate handling of your claim and associated documents.

* for your convenience, click email image (above, right) to compose & direct an email to us regarding your assignment and attach your documents

Thank you in advance for the assignment!
▬ ADC Mgt ▬

Allen Dahle & Co., Inc.
• Fully Licensed & Bonded Independent Insurance Adusters •
New York | New Jersey | Connecticut

| Allen Dahle & Co., Inc. | 914 694.1222 914 694.1222 TEL | 914 694.1550 FAX | allendahle@aol.com |

Allen Dahle & Co., Inc.
427 Bedford Rd - Ste 350
Pleasantville, NY 10540-3041

914 694.1222 914 694.1222 ◄ Office

914 694.1550 ◄ Fax
Corporate Email

► allendahle@aol.com ◄

ADC on Google

Web View Mobile View

Logout Edit page

For Insurance Professionals Only

Direct Assign: CASUALTY LOSS

Your form message has been successfully sent.

Allen Dahle & Co., Inc. 427 Bedford Rd - Ste 350 Pleasantville, NY 10540-3041

Allen Dahle & Co., Inc.
427 Bedford Rd - Ste 350
Pleasantville, NY 10540-3041