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Please use the sections below to provide as much information that is currently known about the assignment. All items marked with a RED * are required.
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CLIENT INFORMATION

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ASSIGNMENT IMFORMATION

Company Name: * Contact Name: * Address: * City: * State: * Zip Code: * Contact Number: * Email: * Preferred Method of Contact: PhoneEmail

Claim or File Project #: * Insured/Client Name: * Insured/Client Phone: Insured/Client Email:

Is point of contact different from above?: YesNo

Point of Contact Name: * Point of Contact Phone: * Point of Contact Email: *

Date of Loss: * Policy Number: Location Address: * Additional Locations: City: * State: * Zip Code: * Loss Summary/Scope of Work Please briefly describe the loss and details and any special instruction along with the services that you would like Flax and Associates to provide. Upload Corresponding Documents: