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New Assignment for Canadian Claims Services Inc.
Your Contact Information
First Name
Last Name
Company
Address (Line 1)
(Line 2)
City
Province
Postal Code
Phone:
eMail:
New Assignment Information
Your Claim #:
Special Instructions:
Characters left:
Insured's Information
Policy #:
Phone #:
Alternate Phone #:
Company:
First Name:
Last Name:
Street Address:
Address 2:
City:
Province:
Postal Code:
Mortgagee:
Loss Location
Street Address:
Address 2:
City:
Province:
Postal Code:
Claimant Information (if applicable)
First Name:
Last Name:
Phone:
Street Address:
Address 2:
City:
Province:
Postal Code:
Loss Information
Date of Loss:
Type of Loss:
Unit:
Type of Adjustment:
Loss Description:
Characters left:
VIN #:
Deductible: