Claims Assignment Form

The Insurance Claims Assignment Form is provided for the convenience of Claims Adjusters to assign claims direct from our website. You can upload any additional insurance form here, if you have multiple forms please email the additional documents directly. No need to duplicate information if attachments contain assignment information.

Insurance Information

Insurance Company:

Examiner Name:

Insurance Phone Number:

Insurance Company Email:

Personal Information

Named of Insured:

Phone Number:

Your Email: (required)

Claim Number:

Policy Number:

Date of Loss:

Policy Period Dates:

Policy Limits:

Hull Type:

Hull Deductible Price:

Motor Type:

Motor Deductible Price:

Trailer Style:

Trailer Deductible Price:

Description of Contents:

Contents Deductible Price:

Boat Information

Vessel Make/Model:

HIN:

Location of Boat:

Repair Facility/Contact for Repairs:

Handling Instructions:

Description of Loss/Damage:

Option to Upload a Document: (Max file size 10MB)

Please acknowledge all information you have provided is accurate and hereby agree to the following Terms and Conditions: (required)
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Insurance Claims Form

Claims Assignment Form

Insurance Information

Personal Information

Policy Limits:

Boat Information