Northern Adjusters Inc.
Assignment/Claim Form

Use this form; or, in the alternative, send assignments to us using your own forms or documents by email to newclaim@nadj.com.

TYPE OF CLAIM:	Auto Property General Liability Other Workers' Comp - Investigation Only WORKERS' COMPENSATION
* Required Fields (Must be filled out before submission)
Type of Assignment: (Required)*	If partial assignment, what do you want us to do?
WHOM DO WE REPORT TO:
Name: (Required)*			Phone: (Required)*
Company:			Fax:
Address: (Required)* (City ST Zip)			Email: (Required)*
Policy #:			Company Claim #:
Date/Time of Accident: (Required)*
INSURED:
Name: (Required)*			Phone: (Required)*
Address: (City ST Zip)
CLAIMANT 1:			CLAIMANT 2:
Claimant Name 1:			Claimant Name 2:
Phone:			Phone:
Address: (City ST Zip)			Address: (City ST Zip)
LOSS:
Location of Accident:
Description of Accident:

INSURED VEHICLE/PROPERTY:
Year:		Make:	Model:
Owners Name:			Phone:
Address: (City ST Zip)
PROPERTY DAMAGED:
Describe Property (If auto, include year, make, model, plate#):

Owner's Name:			Phone:
Address: (City ST Zip)