You MUST have cookies enabled in order for your submission to be successful.

New Assignment for Focus Claims LLC - DBA Dakota Claims Service of Sioux Falls
Your Contact Information
First Name
Last Name
Company
Address (Line 1)
(Line 2)
City
State	AAABAEAKALAPARAZBCCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMBMDMEMIMNMOMSMTNBNCNDNENFNHNJNMNSNTNUNVNYOHOKONORPAPEPRQCRISCSDSKTNTXUTVAVTWAWIWVWYYT
ZIP
Phone:
eMail:
New Assignment Information
Your Claim #:
Assignment Instructions: Characters left:
Insured's Information
Policy #:
Phone #:
Alternate Phone #:
Company:
First Name:
Last Name:
Street Address:
Address 2:
City:
State:	AAABAEAKALAPARAZBCCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMBMDMEMIMNMOMSMTNBNCNDNENFNHNJNMNSNTNUNVNYOHOKONORPAPEPRQCRISCSDSKTNTXUTVAVTWAWIWVWYYT
Zip:
Mortgagee:
Loss Location
Street Address:
Address 2:
City:
State:	AAABAEAKALAPARAZBCCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMBMDMEMIMNMOMSMTNBNCNDNENFNHNJNMNSNTNUNVNYOHOKONORPAPEPRQCRISCSDSKTNTXUTVAVTWAWIWVWYYT
Zip:
Claimant Information (if applicable)
First Name:
Last Name:
Phone:
Street Address:
Address 2:
City:
State:	AAABAEAKALAPARAZBCCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMBMDMEMIMNMOMSMTNBNCNDNENFNHNJNMNSNTNUNVNYOHOKONORPAPEPRQCRISCSDSKTNTXUTVAVTWAWIWVWYYT
Zip:
Agent Information Show | Hide
First Name:
Last Name:
Company:
Office Phone:
Cell Phone:
Street Address:
Address 2:
City:
State:	AAABAEAKALAPARAZBCCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMBMDMEMIMNMOMSMTNBNCNDNENFNHNJNMNSNTNUNVNYOHOKONORPAPEPRQCRISCSDSKTNTXUTVAVTWAWIWVWYYT
Zip:
Country:
Loss Information
Date of Loss:
Type of Loss:	WaterWindFireCollisionDamage by AircraftBackup (Water & Sewer)ExplosionHailIce/SnowOtherSmokeTheftWind/HailVandalismBodily Injury On PremisesClaimant Property DamageComprehensiveCollision with bodily injuryHail damage to vehicleLiabilityDamage By AnimalIce DamLightningAnimal TrespassTornado
Unit:	Residential PropertyCommercial PropertyMobile HomePersonal AutoBusiness AutoN/ATractor/TrailerFarm & RanchRental PropertyWater CraftMotorcycleCamperHeavy EquipmentLivestockCrops
Type of Adjustment:	Limited Full
Loss Description: Characters left:
VIN #:
Deductible:
Wind Deductible:
Coverage ABuilding ContentsOther StructuresDwellingBusiness Personal PropertyUPPLoss Of UseWater Back Up
Coverage BBuilding ContentsOther StructuresDwellingBusiness Personal PropertyUPPLoss Of UseWater Back Up
Coverage CBuilding ContentsOther StructuresDwellingBusiness Personal PropertyUPPLoss Of UseWater Back Up
Coverage DBuilding ContentsOther StructuresDwellingBusiness Personal PropertyUPPLoss Of UseWater Back Up
Endorsements:
Save and Upload  Save without Addtional Upload