Continental Claims
Casualty Assignment Form


Please complete and submit the following information regarding your casualty assignment

Your assignment will be sent to our Facility for processing by our nearest branch office.


NOTE: Fields marked with an asterisk (*) are required.
 Submitted By Contact Information  
First Name:*
Last Name:*
Phone:*
Fax:*
E-mail:*

 Submitted By Company Information  
   
First Name:*
Last Name:*
Company Name:*
Street Address:*
Street Address (cont):
City:*
State / Province:*
Zip / Postal code:*
Contact Phone:*
Contact Fax:*
Contact E-Mail:*

 Policy Information  
Policy Number:
  Please use MM/DD/YYYY format
Policy Effective Date:

 Loss Information  
  Please use MM/DD/YYYY format

Date of Loss:*

Customer Claim #:
Location of Loss:

Brief Description of Loss:*

Were Police Called?
Was Fire Dept Called?

Complaint/Police Report #


 Insured Information  
Insured Person / Company:*
Contact First Name:
Contact Last Name:
Insured Address:
Insured Address (cont):
City:
State / Province:
Zip / Postal code:
Insured Home Phone:
Insured Work Phone:

 Claimant Information  
Claimant First Name:
Claimant Last Name:
Claimant Address:
Claimant Address (cont):
City:
State / Province:
Zip / Postal code:
Claimant Home Phone:
Claimant Work Phone:
Injured Party First Name:
Injured Party Last Name:
Description of Injury(ies):

 Witness Information  
Witness First Name:
Witness Last Name:
Witness Address:
Witness Address (cont):
City:
State / Province:
Zip / Postal code:
Witness Home Phone:
Witness Work Phone:
Action(s) to take /
Special Instructions:
   
Preferred Method of confirmation
from CCS:
 
Please click the Submit button only ONCE. It may take a few minutes for your claim to be processed. You will receive a confirmation once your assigment has been sent.