INSURANCE CLAIM ASSIGNMENT FORM
	To assign us a job electronically, fill out this form, and hit the Submit button at the bottom. Even if you don't have all the information, feel free to get started now. Fill in the information you do have, click the Submit button at the bottom of the form, and an FDI representative will contact you via phone or e-mail to fill in the blanks.

	CONTACT INFORMATION
	Name
	Company
	Address
	City
	State
	Zip
	Phone
	Fax
	E-mail
	CLAIM INFORMATION
	Carrier Name
	File #
	Date of Loss
	Insured
	Address
	City
	State
	Zip
	Phone
	Fax
	E-mail
	Claimant/Contact
	Address
	City
	State
	Zip
	Phone
	Loss Location
	(if different)
	City
	State
	Zip
	DAMAGE / LOSS INFORMATION
	Describe Loss
	Scope of Service
	Other Notes
	REPORTING INFORMATION
	Report To	You
		Other
	Name
	Company
	Address
	City
	State
	Zip
	INVOICE INFORMATION
	Invoice To	You
		Other
	Name
	Company
	Address
	City
	State
	Zip