Continental Claims
Catastrophe Assignment Form


Please complete and submit the following information regarding your catastrophe 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:*

 Loss Information  
  Please use MM/DD/YYYY format

Date of Loss:*

Customer Claim #:
Location of Loss:

Brief Description of Loss:*


 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:
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.