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New Assignment for Legion Claims, LLC
Your Contact Information
First Name
Last Name
Company
Address (Line 1)
(Line 2)
City
State	AAABAEAKALAPARAZBCCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMBMDMEMIMNMOMSMTNBNCNDNENFNHNJNMNSNTNUNVNYOHOKONORPAPEPRQCRISCSDSKTNTXUTVAVTWAWIWVWYYT
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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:	General LiabilityWindHailWaterHurricaneFireFloodMiscellaneousEnvironmentalEarthquakeBusiness Interruption- PandemicEvent Cancellation- PandemicAuto Liability Appraisal Only - Heavy EquipmentAppraisal Only - MiscellaneousAuto Liability - CommercialWorkers' CompensationCargoTPA - Vehicle LiabilityTPA - General LiabilityTPA - Workers' CompensationSubrogationAuto Liability - Third PartyGarage Keepers LiabilityGeneral Liability - Commercial
Unit:	Residential - DailyResidential - CATCommercial - DailyCommercial - CATEnvironmentalLarge LossAuto - CATAuto - LiabilityAuto - CollisionHome OfficeAuto- ComprehensiveCaptive ClaimFlood- RatingFlood- ResidentialFlood- Manufactured HomeFlood- Small CommercialFlood- Large CommercialFlood- RCBapSlip / Trip / FallFalling ObjectAssault / BatteryHit Claimant in Rear of VehicleContract WorkStruck By ObjectBurn / ElectricutionSprain / StrainPower SurgeHit and RunInsured Vehicle Rear-EndedMechanical FailureInsured Vehicle Hit Stationary ObjectBus Door Shut on ClaimantPassenger Thrown Off Seat from Sudden StopContusion / CutAltercation with Another StudentStolen VehicleHit domestic animalHit Pedestrian Inhaled FumesFatalityCollapseGunshotElectric ShockAttacked by StudentGas / Chemical DischargeFood Poisoning / Illness
Type of Adjustment:	Limited Full
Loss Description: Characters left:
VIN #:
Deductible:
Wind Deductible:
Coverage AClaim ReserveAdjuster FeesAdjuster ExpensesAdmin FeeMedical
Coverage BClaim ReserveAdjuster FeesAdjuster ExpensesAdmin FeeMedical
Coverage CClaim ReserveAdjuster FeesAdjuster ExpensesAdmin FeeMedical
Coverage DClaim ReserveAdjuster FeesAdjuster ExpensesAdmin FeeMedical
Endorsements:
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