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New Assignment for Value Claims Service, LLC dba Dakota Claims Service of Ainsworth
Your Contact Information
First Name
Last Name
Company
Address (Line 1)
(Line 2)
City
State
ZIP
Phone:
eMail:
New Assignment Information
Your Claim #:
Assignment Instructions:
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Insured's Information
Policy #:
Phone #:
Alternate Phone #:
Company:
First Name:
Last Name:
Street Address:
Address 2:
City:
State:
Zip:
Mortgagee:
Loss Location
Street Address:
Address 2:
City:
State:
Zip:
Claimant Information (if applicable)
First Name:
Last Name:
Phone:
Street Address:
Address 2:
City:
State:
Zip:
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Loss Information
Date of Loss:
Type of Loss:
Unit:
Type of Adjustment:
Loss Description:
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VIN #:
Deductible:
Wind Deductible:
Endorsements:
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