Sams & Associates - Insurance Services

New Loss Assignment

To submit a New Loss Assignment, please complete the form below. You can send it electronically to us, by clicking the Submit button, or you can print the form, complete it and fax it to us at:

Sams & Associates 4080 Cavitt Stallman Road #100
Granite Bay, CA 95746 1-800-566-7267 Fax: (916) 786-4660

DATE:
DATE OF LOSS:
CLAIM NO.:
COMPANY:
COMPANY ADDRESS:
ADJUSTER:
TELEPHONE:
EXTENSION:
Would you like your reports sent electronically?	YES NO
EMAIL:
TYPE OF LOSS:
	FULL ASSIGNMENT LIMITED ASSIGNMENT
FACTS OF LOSS: You may type or paste details here.

INSURED/CONTACT:
Last Name:
First:
Home Phone:
Work Phone:
CONTACT:
Last Name:
First:
Home Phone:
Work Phone:
ADDRESS:
Street:
Apt/Box:
City:
State:
Zip:
CLAIMANT/CONTACT:
Last Name:
First:
Home Phone:
Work Phone:
CONTACT:
Last Name:
First:
Home Phone:
Work Phone:
ADDRESS:
Street:
Apt/Box:
City:
State:
Zip:

INSTRUCTIONS
STATEMENTS:
OF	CLAIMANT(S) INSURED(S) WITNESS(ES)
CHECK ALL APPLICABLE ITEMS
SCENE PHOTOS	OFFICIAL REPORTS (POLICE/FIRE)
DIAGRAM	HANDLE AND CONTROL BI CLAIM
SCOPE OF DAMAGES	INDEX INFO
ESTIMATE OF REPAIRS	MED/WAGE AUTH
PILR	ACTIVITY CHECKS
GET AGREED PRICE	SUBMIT TRACE REQUEST
DETERMINE CAUSE	VEHICLE PHOTOS
OBTAIN INSURED'S RECORDS	ASSIGN VEHICLE APPRAISAL
COMPLETE INVENTORY, ACV
OTHER INFORMATION:
A printable copy of this form will appear after you click the Submit button.


Thank you for contacting Sams & Associates.

Sams & Associates
4080 Cavitt Stallman Road #100
Granite Bay, CA 95746
1-800-566-7267
Fax (916) 786-4660
email: sams@sams-assoc.com