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New Assignment for W.L. Stewart & Associates, Inc.
Your Contact Information
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Assignment Instructions:
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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
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NS
NT
NU
NV
NY
OH
OK
ON
OR
PA
PE
PR
QC
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TX
UT
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VT
WA
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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
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UT
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VT
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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
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YT
Zip:
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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:
Water Damage
Homeowner
Commercial Property
Auto Property Damage
Commercial Auto
Liability
Wind and/or Hail
Theft
Fire
Collision with Bodily Injuries
Spoilage
Bodily Injury on Premises
Property Damage
Appraisal
LIghtning
Cargo
Food Poisoning
Garage
Collision
PIP
Other
Unit:
Appraisal
Property Damage
Bodily Injury on Premises
Spoilage
Collision with Bodily Injuries
Fire
Commercial Auto
Commercial Property
Liability
Commercial General Liability
Homeowner
Mediation
Cargo
Garage
Auto
Inland Marine
Type of Adjustment:
Limited
Full
Loss Description:
Characters left:
VIN #:
Deductible:
Wind Deductible:
Coverage A
Coverage B
Coverage C
Coverage D
Endorsements:
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