Continental Claims
Motor Vehicle Assignment Form

Please complete and submit the following information regarding your motor vehicle 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 a Ticket Issued?
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:

 Insured Vehicle Information  
Vehicle Plate/Tag Number:*
Vehicle Make: *
Vehicle Model: *
Vehicle VIN:
Driver's First Name: *
Driver's Last Name: *
Driver's Home Phone:
Driver's Work Phone:*
Damage Description:
Is Car Driveable?
If not, where is vehicle?

 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:

 Claimant Vehicle Information  
Vehicle Plate/Tag Number:*
Vehicle Make: *
Vehicle Model: *
Vehicle VIN:
Driver's First Name: *
Driver's Last Name: *
Driver's Home Phone:
Driver's Work Phone:
Damage Description:
Is Car Driveable?
If not, where is vehicle?

Action(s) to take /
Special Instructions:
   
Preferred Method of confirmation
from CIA:
 
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.