FILE CLAIM ONLINE

ABOUT CICA

These Pages Under Construction & Will be Ready for Use Spring 2004

Online Claim Assignment Form

Please complete the following form to the best of your ability. If you have any questions, please feel free to contact us at the number or e-mail below.

If you wish to print this form for your records, select the print function in your browser prior to hitting the SUBMIT button at the bottom.

Agency Information
Policy Number
Claim Number
Policy Period
Adjuster Information
Date of Loss
Date Reported
Date Assigned
Insured Name
Insured Address
Location #
Item #
Insured Location
Insured Home Phone
Insured Work Phone
Location of Loss
Description of Loss
LSL/Cause
Cause Desc.
Loss Reserve
Policy Coverages, Limits, Deductables & Other Interests
Coverage Effective date
Deductable
Basic Policy
COV-A
COV-B
COV-C
COV-D
COV-E
COV-F
Construction
#of Fam
Program
Yr Built
Res Employees	Yes No
Sq. Feet
# Fireplaces
Attached Garage?	Yes No
# Cars
Pool?	Yes No
Endorsements Effective
Special instructions

If you wish to print this form for your records, select the print function in your browser prior to hitting the SUBMIT button.

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© Copyright 2003 Coventry Insurance Claims Adjusting, Inc.. All rights reserved.
Phone: 818-896-7444 Fax: 818-897-3405 E-mail: mc@coventryadjusting.com