LIABILITY CASE REFERRAL

Date:

YOUR INFORMATION

Name:

Title:

Company/Firm:

Street/PO Box:

City:  

State:   Zip Code:

Phone Number(s):

Fax Number:

Email Address:

Your File #:

Copy of HCI Reporting to Attorney/Carrier? Yes No

If Yes, Send Attachments with Copy? Yes No

Name & Mailing Address for Copy: 

City: State: Zip:

ASSIGNMENT INFORMATION

Type of Assignment: (Check all that apply)

Insured Statement    Witness Statement

Claimant Statement  Witness Canvas

Scene Photos      Scene Diagram

Product Photos    Damages Photos

Secure/Copy Documents Trial Prep

Serve Subpoena(s) Coverage Investigation

Other (Provide details below)

Prior HCI File Number:
 (If reopening previous assignment to HCI)

Reservation of Rights or Non-Waiver Agreement:

N/A     Needed     Issued Already (Please send a copy)

Insured/Client:

Contact Person:

Mailing Address:

Street/PO Box:

City:State:  Zip Code:

Policy Number:

Phone Number(s):

Fax Number:

Email Address:

Claimant:

Mailing Address:

Street/PO Box:

City:State:Zip Code:

Street Address (if different):

City: State: Zip Code:

Date of Birth:

SSN:

Gender: Male Female

Phone number(s):

Email Address:

Occupation:

Employer:

Spouse:

Drivers License #:

Vehicle Type(s) & Plate #(s):

Physical Description:

Is Claimant Represented? Yes No (Include attorney info)

 

Any Additional Claimants? Yes No (Include information details below)

Date of Loss:

Date Reported:

Location of Loss:

Description of Loss:

Alleged Injury/Damages:

Investigation Needed:

Are there any specific questions that need to be asked?

Are there any specific documents that need to be obtained?

Police Report

Fire Department Report

OSHA Report

Medical Authorizations (Generic or Specific Forms to be supplied?)

Medical Reports direct from Claimant

Other

Are there any important deadline dates that need to be met?

Are there any circumstances where you do not want a signed statement to be taken?

Is there any third party &/or insurance carrier contact needed?

Are there any special claim handling or billing requirements?

 

 

Will supporting documentation be sent to HCI for this assignment?

Yes No

If Yes, how will it be sent? Mail Fax Scanned to Email

Additional Details and/or Information:

The more information you give us, the better service we can provide!

Thank you for this assignment.