You MUST have cookies enabled in order for your submission to be successful.
New Assignment for CLOSED - Dakota Claims Service of Spearfish, LLC
Your Contact Information
First Name
Last Name
Company
Address
(Line 1)
(Line 2)
City
State
AA
AB
AE
AK
AL
AP
AR
AZ
BC
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MI
MN
MO
MS
MT
NB
NC
ND
NE
NF
NH
NJ
NM
NS
NT
NU
NV
NY
OH
OK
ON
OR
PA
PE
PR
QC
RI
SC
SD
SK
TN
TX
UT
VA
VT
WA
WI
WV
WY
YT
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:
AA
AB
AE
AK
AL
AP
AR
AZ
BC
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MI
MN
MO
MS
MT
NB
NC
ND
NE
NF
NH
NJ
NM
NS
NT
NU
NV
NY
OH
OK
ON
OR
PA
PE
PR
QC
RI
SC
SD
SK
TN
TX
UT
VA
VT
WA
WI
WV
WY
YT
Zip:
Mortgagee:
Loss Location
Street Address:
Address 2:
City:
State:
AA
AB
AE
AK
AL
AP
AR
AZ
BC
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MI
MN
MO
MS
MT
NB
NC
ND
NE
NF
NH
NJ
NM
NS
NT
NU
NV
NY
OH
OK
ON
OR
PA
PE
PR
QC
RI
SC
SD
SK
TN
TX
UT
VA
VT
WA
WI
WV
WY
YT
Zip:
Claimant Information
(if applicable)
First Name:
Last Name:
Phone:
Street Address:
Address 2:
City:
State:
AA
AB
AE
AK
AL
AP
AR
AZ
BC
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MI
MN
MO
MS
MT
NB
NC
ND
NE
NF
NH
NJ
NM
NS
NT
NU
NV
NY
OH
OK
ON
OR
PA
PE
PR
QC
RI
SC
SD
SK
TN
TX
UT
VA
VT
WA
WI
WV
WY
YT
Zip:
Agent Information
Show
|
Hide
First Name:
Last Name:
Company:
Office Phone:
Cell Phone:
Street Address:
Address 2:
City:
State:
AA
AB
AE
AK
AL
AP
AR
AZ
BC
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MI
MN
MO
MS
MT
NB
NC
ND
NE
NF
NH
NJ
NM
NS
NT
NU
NV
NY
OH
OK
ON
OR
PA
PE
PR
QC
RI
SC
SD
SK
TN
TX
UT
VA
VT
WA
WI
WV
WY
YT
Zip:
Country:
Loss Information
Date of Loss:
Type of Loss:
_________________
Bodily Injury
Cargo
Collapse
Collision
Comprehensive
Deer
Earth Movement
Fatality
Fire
Freeze
Hail
Hit and Run
Ice Dam
Liability
Lightning
Other
Rollover
Property Damage
Power Outage
Scene Photos Only
Sewer Back Up
Slip & Fall
Subrogation
Sump Pump Failure
Theft
Unknown
Vandalism
Water
Weight Ice/Snow
Widow Status
Wind
Wind/Hail
Workers' Comp
Unit:
_________________
Apartment/Condo Property
ATV
Auto/Pick-Up Truck
Cargo
Church Property
Commercial Heavy Equipment
Commercial Tools/Equipment
Commercial Property
Farm/Ranch Animals
Farm/Ranch Crops
Farm/Ranch Equipment
Farm/Ranch Property
Liability
Marine - Watercraft
Mobile Home
Motorcycle
Personal Property
Rental, Single Family
Residential Property
RV - Fifth Wheel Trailer
RV - Motorhome
RV - Travel Trailer
Semi - Tractor/Truck
Semi - Tractor & Trailer
Semi - Trailer
Specialty Vehicle
Snowmobile
Townhouse
Utility Trailer
Type of Adjustment:
Limited
Full
Loss Description:
Characters left:
VIN #:
Deductible:
Wind Deductible:
Coverage A
Building 1
Business Personal Property
Coverage A-Dwelling
Coverage C-Contents
Coverage B
Building 1
Business Personal Property
Coverage A-Dwelling
Coverage C-Contents
Coverage C
Building 1
Business Personal Property
Coverage A-Dwelling
Coverage C-Contents
Coverage D
Building 1
Business Personal Property
Coverage A-Dwelling
Coverage C-Contents
Endorsements:
Save and Upload
Save without Addtional Upload