Dakota Claims Service - Send An Assignment

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Send An Assignment

Instructions for Assignment

Insured Recorded Statement		Agreed Cost of Repair Insured Vehicle
Claimant Recorded Statement		Agreed Cost of Repair Claimant Vehicle
Witness Recorded Statement		Total loss of Evaluation
Photo/Diagram/Measurements of Scene		Move Salvage A.S.A.P.
Obtain Police Report		Agreed Price Appraisal Audit Service
Canvass for Witness		Handle Subrogation
Rule out Bodily Injury		Determine Comparative Negligence
Obtain Medical Authorization		Propery Appraisal Service
Obtain Wage Authorization		Other
	please specify other:

Loss Information

Producer:		Policy Number:
Date of Loss:
Effective Date:		Expiration Date:
Insured Name:		Address:
Telephone:
Loss Location & Description:
Authority Contacted:		Report #:
Violations:
Loss Payee:		Deductible:
Insured Vehicle-Year:		Make:
Model:		VIN:
Damaged Area:
Owner Name & Address:		Telephone:
Driver Name & Address:		Telephone:
Where can insured vehicle be seen:
Where can claimant vehicle be seen:
Description of claimant property damage:
Claimant Name & Address:		Telephone:
Injured Parties Name & Address:		Telephone:
Extent of Injury:
Other Info:

Please send to: