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Required fields*
  • Client
  • Insured
    • Last Name/Business *
      First Name
      Address *
      City, State, Zip Code *
       
      select
      Country *
      select
      Phone 1 * x

      Phone 2 x
      Email
  • Claimant
    • Claimant Last Name
      Claimant First Name
      Address
      City, State, Zip Code
       
      select
       
      Country
      select
      Phone
      x
       
      Email
  • Assignment
    • Type of Assignment *
      select

      Loss Description *

      Words:0 Characters:0    
      Loss Location *

      Address *
      City, State, Zip Code *
       
      select
      Country *
      select
       
      Assignment *
      (what do you want
      Crawford to do)

      Words:0 Characters:0  
      Assignment of Work Location

      Address *
      City, State, Zip Code *
       
      select
       
      Country *
      select
        Please enter the correct Zip Code here.
      This assignment will be sent to the appropriate Crawford service center based on this Zip Code
      .
      Phone
      x
      Fax #
      Email
  • Injury/Damage/Coverage
    •  
      Injury/Damage

      Words:0 Characters:0  
       
      Coverage Information *

      Words:0 Characters:0  
Attachments
*Individual file size must not exceed 5MB
 
 

 
 
 
 
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