Vendor Assignment Form


Assignment Information
Company Adjuster Code:  
Claim number   Date of loss
(mm/dd/yyyy)
 
Adjuster Information:
First Name:   Email:
Last Name:   Phone:
 
Owner information:
First name   Last name
 
Lien Holder yes  no  
 
Insured information:
First name   Last name  
Phone   Address  
City   State  
Zip code  
Email  
Ok To Text yes no  
 
Unit information:  
Year   Make
Model   Color  
License plate   Serial number (VIN)
Number of plates   Unit ACV  
Reserve  
Title Brand  

Damage description/other information
 
Pick up information:
Location
Address   Phone (###-###-####)
City   State
Zip code  
 
Is The Unit Towable yes no  
Has keys yes no  
Has engine yes no  
Has transmission yes no  
Has personalized plates yes no