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New Assignment for Specialty Group, Inc.
Your Contact Information
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Last Name
Company
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State
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AP
AR
AZ
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CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
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MB
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MI
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MS
MT
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PE
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New Assignment Information
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Assignment Instructions:
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Insured's Information
Policy #:
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Alternate Phone #:
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First Name:
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Address 2:
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AA
AB
AE
AK
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AR
AZ
BC
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MI
MN
MO
MS
MT
NB
NC
ND
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NF
NH
NJ
NM
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NT
NU
NV
NY
OH
OK
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OR
PA
PE
PR
QC
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TX
UT
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Zip:
Mortgagee:
Loss Location
Street Address:
Address 2:
City:
State:
AA
AB
AE
AK
AL
AP
AR
AZ
BC
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MI
MN
MO
MS
MT
NB
NC
ND
NE
NF
NH
NJ
NM
NS
NT
NU
NV
NY
OH
OK
ON
OR
PA
PE
PR
QC
RI
SC
SD
SK
TN
TX
UT
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Zip:
Claimant Information
(if applicable)
First Name:
Last Name:
Phone:
Street Address:
Address 2:
City:
State:
AA
AB
AE
AK
AL
AP
AR
AZ
BC
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MI
MN
MO
MS
MT
NB
NC
ND
NE
NF
NH
NJ
NM
NS
NT
NU
NV
NY
OH
OK
ON
OR
PA
PE
PR
QC
RI
SC
SD
SK
TN
TX
UT
VA
VT
WA
WI
WV
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YT
Zip:
Agent Information
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First Name:
Last Name:
Company:
Office Phone:
Cell Phone:
Street Address:
Address 2:
City:
State:
AA
AB
AE
AK
AL
AP
AR
AZ
BC
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MI
MN
MO
MS
MT
NB
NC
ND
NE
NF
NH
NJ
NM
NS
NT
NU
NV
NY
OH
OK
ON
OR
PA
PE
PR
QC
RI
SC
SD
SK
TN
TX
UT
VA
VT
WA
WI
WV
WY
YT
Zip:
Country:
Loss Information
Date of Loss:
Type of Loss:
AA - Appraisal - Arbitration
AC - Activity Check
AF - Automobile Fire
AG - Auto Garage Liability
AH - Liability (Heavy Equipment)
AL - Auto Liability
AL-BI - Auto Liability (Bodily Injury)
AL-PD - Auto Liability (Property Damage)
AP - Appraisal (Auto)
AT - Automobile Theft
AW - Alive & Well Check
CO - Cause & Origin
CAT - Catastrophe
CAT - Michael
CAT-TE - CAT Billed At Time & Expense
CD - Construction Defect
DS - Data Search
EN - Environmental
EUO - Examination Under Oath
FL - Flood
FL-AC - Flat Rate (Activity Check)
FL--AU - Flat Rate (Auto)
FL-AW - Flat Rate (Alive & Well Check)
FL-BI - Flat Rate (GL-BI)
FL-LCI - Flat Rate (Loss Control Inspection)
FL-LI - Flat Rate (Liability)
FL-ME - Flat Rate (Mediation)
FL-PD - Flat Rate (GL-PD)
FM - Inland Marine
GL - General Liability
GL-BI - General Liability (Bodily Injury)
GL-PD - General Liability (Property Damage)
HE - Heavy Equipment
LO - Liability (Other)
ME - Mediation
ME-CD - Mediation (CD)
MH - Mobile Home
ML - Malpractice Liability
MS - Miscellaneous
OM - Ocean Marine
OT - Other
PIP - Personal Injury Protection
PL - Product Liability
PP - Property Appraisal
PP-IIC - Property Appraisal (Ironshore)
PR - Property
PRP - Police Report Pickup
PR-SCH - Property Fee Schedule
SIU - Fraud Investigation
SUBRO - Subrogation
SV - Surveillance
TB - Theft & Burglary
TE - Temporary Employment
TPA - Third Party Administration
TPA-WC - Third Party Administration (WC)
WC - Workers' Compensation
WC-AC - Workers' Compensation (Activity Check)
WC-SCH - WC Schedule
CAT - TA (Temp Assignment)
CAT - Dorian
CAT-2019
CAT-2020
CAT-2021
CAT-2023
CAT-2025
CAT-2026
CAT-2030
CAT-2033
CAT-2044
CAT-2063
CAT-2071
CAT-2074
CAT-2115
CAT-2116
CAT-2117
CAT-2120
CAT-2121
CAT-2122
CAT-2123
CAT-2124
CAT-2125
CAT-2126
CAT-2127
CAT-2128
CAT-2129
CAT-2130
CAT-2131
CAT-2132
CAT-2133
CAT-2134
CAT-2135
CAT-2136
CAT-2137
EVENT-2138 (CLAUDETTE - PR)
EVENT-2138 (CLAUDETTE)
EVENT - DANNY
CAT-2141 (ELSA - PR)
CAT-2160
EVENT - 2211 (PR)
EVENT - 2211 (EVENT)
EVENT - 2176 (PR)
EVENT - 2176 (EVENT)
Unit:
N/A
Residential
Commercial
Type of Adjustment:
Limited
Full
Loss Description:
Characters left:
VIN #:
Deductible:
Wind Deductible:
Coverage A
Coverage B
Coverage C
Coverage D
Endorsements:
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