ICS Claims
930 Sunrise Highway
West Babylon, NY 11704

PH 631-422-1268
FX 631-422-1246

email@icsclaims.net

Casualty Assignment Sheet:

Email Address:
(You will recieve a copy of this form if your email address is entered here.)

Todays Date:

Company:
Address:
City: State: Zip:
Policy #:
Claim #:
Claim Rep:
Telephone: xt:
Email:
Insured:
Address:
City: State: Zip:
Telephone
(W)
(H)
(O)
Loss Location:
Address:
City: State: Zip:
Contact Person:
Telephone:

Date of Loss:

Description of Loss:
Claimant:
Address:
City: State: Zip:
Telephone:
Witness:
Address:
City: State: Zip:
Telephone:
Task Assignment:
Remarks

Attach Files
Number of Files to Attach:

New Assignments Page

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