Heinrich and Company

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Please fill out this form if you have a new liability assignment.

From (required):	Insurance Company Self-Insured
Report To:
Email Address (required):
Phone Number (required):
Fax:
Agent:
Phone:
Claim #:
Policy #:
Deductible:
Date of Loss:

INSURED

Name:
Address:
City, State, Zip:
Home Phone:
Work Phone:

CLAIMANT

Name:
Address:
City, State, Zip:
Home Phone:
Work Phone:

Type of liability coverage involved:
Automobile
Homeowners
Farmowners
Truck
General Liability
Professional
Liquor
Aircraft
Other

If automobile, vehicle is:

Make:
Model:
Year:
VIN:
Location:

Location of Accident:

Description of Accident:

Authorites involved:
Fire Department
Police Department
Fire and Police Departments
State Patrol
State Fire Marshall
Sheriff's Department
State Crime Bureau
Other

Officer's Name:
Phone#:
Agency Location:

Injured parties/insured vehicle:

Name:
Address:
Phone:

Name:
Address:
Phone:

Insured parties/claimant vehicle:

Name:
Address:
Phone:

Name:
Address:
Phone:

Witnesses:

Describe Activity Requested of Heinrich and Company: