International Catastrophe Assessment Team

CLAIM NOTICE ACKNOWLEDGMENT AND ASSIGNMENT                        (786)294-6815  FAX (800) 544-9495


       
Insured   Insurance Company
ADDRESS: ADDRESS:
CITY: CITY:
STATE:                                                ZIP CODE:          STATE:                        ZIP CODE:  
Home#                  Work #          CONTACT PERSON:
Cell #                                Email:        CONTACT NUMBER:

LOSS LOCATION         Same as above                                                          Agent

ADDRESS:       ADDRESS:
  
CITY:    CITY:  
STATE:                        ZIP CODE:             STATE:                   ZIP CODE:

Claim No.

 Policy No.

 Effective Date

 Expiration Date

 Loss Date

 Date Received

 Date Assigned


Cause of Loss:

 
Special Instructions:




 

Item Limit of Liability  Deductible

single per coverage

  Coins % Form Numbers Insured Property and Form Description
   

   

   

   

  Mortgagee  ADDRESS: Loan No.
Prior Loss                                RCV AMOUNT OF LOSS

Flood Carrier                                                                                          Flood Policy No. 


 

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