Property/Inland Marine Assignment Notice

Insured
County *
Address
Zip Code
Person to Contact *
Contact's Business Phone *
Loss
Date and Time of Loss *
Police or Fire Department reported to
Cause of loss (i.e. wind damage, water damage, lightning, etc)*
Projected amount of entire loss *
Description of loss and damage *
What was involved from your Property
Description of Building/PP/IM Equipment *
Address of Building/PP/IM Equipment *
Remarks
Miscellaneous
Form Preparer's Name *
Form Preparer's Title *
Form Preparer's Phone Number *
Date Prepared *