NCS Assign a Claim

Company Information
Company
Company Address
Company City		ZIP
Email	*
Company Adjuster	*	Adjuster Number
FAX Number

Attach files
The files should contain all the insured loss, coverage, and agency information.
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If you do not have files to attach, please complete information below.

Insured Information
Date Assigned
Insured
Insured Address
Insured City		ZIP
Loss Location
Phone Number		Cell Number

Coverage Information
Date of Loss
Policy Number		Claim Number
Type of Claim
Description of Loss
Start Term		Policy Term
Deductible
Coverage A
Coverage B
Coverage C
Coverage D

Agency Information
Agency		Agency Number
Agency Address
Agency City		ZIP