RIVERVIEW CLAIMS SERVICE, INC

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Please fax your assignment to 1-800-942-9523 or complete this form.

GENERAL LOSS ASSIGNMENT NOTICE FORM

( Please fill in the form fields that are appropriate for your requested assignment. )
  *TYPE    
   Auto
Property
Casualty		 Truck
Scene Investigation
Special Investigation		 Farm
Heavy Equipment		  
   
 *ASSIGNMENT REQUEST    
   Full
Partial		  
  
  SPECIAL INSTRUCTIONS: 
  
  CLIENT    
*Client Name:   
*Address 1:   
Address 2:   
*City:   
*State:   
*ZIP:   
*Business Phone:   
Email:   
*Person to Report to:   
  LOSS    
*Client Claim No.:   
*Date:   
Time:   
*Location:   
City:   
State:   
Description:   
Police Report:  Yes
No		  
Location of Police Report:   
  
  POLICY  
Policy No.: 
Policy Inception Date: 
Beginning Policy Term: 
Ending Policy Term: 
Bodily Injury: 
Property Damage: 
Single Limit: 
Medical Payment: 
Lien Holder
Collision Deductible: 
Comprehensive Deductible: 
Dwelling: 
Other Structures: 
Personal Property: 
Additional Living Expense: 
Property Deductible: 
Other coverage & Deductibles
(UM, no-fault, towing, etc.)
  
  INSURED VEHICLE    
Year:   
Make:   
Model:   
VIN:   
Plate No:   
  VEHICLE DRIVER    
Name:   
Address 1:   
Address 2:   
City:   
State:   
ZIP:   
Residence Phone:   
Business Phone:   
Email:   
Residence Phone:   
Business Phone:   
Relation to the Insured: 
(Employee, Family, etc.)		  
Date of Birth:   
Driver's License No.:   
Damage Description:   
Amount Estimated:   
Where can the vehicle be seen?  
When?  
  
  VEHICLE OWNER    
Name:   
Address 1:   
Address 2:   
City:   
State:   
ZIP:   
Residence Phone:   
Business Phone:   
Email:   
  
  PROPERTY DAMAGED  
Property Description: 
Property Damage of Loss: 
Miscellaneous Information: 
(I.e. business interruption or other coverages)
Loss Payee or Mortgage Holder: 
Company/Agency Name: 
  PROPERTY OWNER    
Name:   
Address 1:   
Address 2:   
City:   
State:   
ZIP:   
Residence Phone:   
Business Phone:   
Email:   

 

  
  INJURED NO 1    
Name:   
Address 1:   
Address 2:   
City:   
State:   
ZIP:   
Residence Phone:   
Business Phone:   
Email:   
Age:   
Injury Description:   
  INJURED NO 2    
Name:   
Address 1:   
Address 2:   
City:   
State:   
ZIP:   
Residence Phone:   
Business Phone:   
Email:   
Age:   
Injury Description:   
  
  INJURED NO 3    
Name:   
Address 1:   
Address 2:   
City:   
State:   
ZIP:   
Residence Phone:   
Business Phone:   
Email:   
Age:   
Injury Description:   
  INJURED NO 4    
Name:   
Address 1:   
Address 2:   
City:   
State:   
ZIP:   
Residence Phone:   
Business Phone:   
Email:   
Age:   
Injury Description:   
  
  WITNESS OR PASSENGER NO 1    
Name:   
Address 1:   
Address 2:   
City:   
State:   
ZIP:   
Residence Phone:   
Business Phone:   
Email:   
Other (Specify):   
Remarks: 
(Include Adjuster Assigned)		  
Description of Accident:   
  WITNESS OR PASSENGER NO 2    
Name:   
Address 1:   
Address 2:   
City:   
State:   
ZIP:   
Residence Phone:   
Business Phone:   
Email:   
Other (Specify):   
Remarks: 
(Include Adjuster Assigned)		  
Description of Accident:   
  
Use the Assign button below to send the claim to Riverview Claims Service, Inc. Click Reset to clear all fields in order to erase errors or prepare to send another claim.
We appreciate your business and thank you.


Fax: 1-800-942-9523
Email: contact us
P.O. Box 116 P.O. Box 1377
La Crosse Madison
WI 54602 WI 53701
Phone: 608-783-9000 Phone: 608-259-9000


Riverview Claims Service, Inc. 2000. All rights reserved.