Heinrich and Company

Please fill out this form if you have a property loss assignment regarding homeowners, commercial property, or farmowners.

Type of assignment:
Full adjustment, including cause, coverage, and subrogation.
Full adjustment of loss without cause, coverage, or subrogation.
Appraisal only

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

INSURED

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

CLAIMANT

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

Insurance Information:

Type of policy:
Homeowners
Farmowners
Commercial Property
Dwelling Policy
Business Owners
Other

Amount of coverage:
Building $
RC yes no

Contents $
RC yes no

Other $
RC yes no

Deductible (basic):
$100.00
$250.00
$500.00
$1000.00
Other

Deductible (wind and hail):
$100.00
$250.00
$500.00
$1000.00

Location of Property:

Type of property:
Dwelling
Dwelling and contents
Dwelling related structure and contents
Contents only
Farm dwelling
Farm real property other than dwelling
Farm personal property
Commercial property
Government or municipal property
Business property
Inland marine
Other

Contact person if different from insured:
Name:
Phone:

Cause of loss (peril):
Wind
Hail
Fire
Smoke
Overflow or plumbing discharge
Electrical currents
Vehicle damage
Tornado
Flood
Sump pump failure
Freezing
Vandalism
Theft
Burglary
Other

Authorities 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:

Special instructions, comments, or remarks:

Please send to: