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Casualty Claims
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Casualty Assignment Form

Please complete and submit the following information regarding your casualty assignment

Your assignment will be forwarded to our nearest branch office for processing.

Please contact us with any questions or comments.

NOTE: Fields marked with an asterisk (*) are required.

Office Location
Select the Littleton location to handle your claim below. If you are unsure please select the "Corporate Office" location.
Office Location:
Submitted By Company Information
First Name:*
Last Name:*
Contact E-Mail:*
Company Name:*
Street Address:*
Street Address (cont):
City:*
State / Province:*
Zip Code:*
Contact Phone:*
Contact Fax:

Policy Information
Policy Number:
Policy Effective Date: (MM/DD/YYYY)

Loss Information
Date of Loss:* (MM/DD/YYYY)
Customer Claim #:
Location of Loss:
Brief Description of Loss:*
Were Police Called?
Police Dept. Name
Was Fire Dept. Called?

Insured Information
Insured Person / Company:*
Contact First Name:
Contact Last Name:
Insured Address:
Insured Address (cont):
City:
State/Province:
Zip Code:
Insured Home Phone:
Insured Work Phone:
Insured Mobile Phone:
Injured Party First Name:
Injured Party Last Name:
Description of Injury(ies):

Claimant Information
Claimant First Name:
Claimant Last Name:
Claimant Address:
Claimant Address (cont):
City:
State / Province:
Zip Code:
Claimant Home Phone:
Claimant Work Phone:
Claimant Mobile Phone:
Injured Party First Name:
Injured Party Last Name:
Description of Injury(ies):

Witness Information
Witness First Name:
Witness Last Name:
Witness Address:
Witness Address (cont):
Witness City:
Witness State/Province:
Zip Code:
Witness Home Phone:
Witness Work Phone:

Special Instructions:
Preferred Method of Confirmation
from The Littleton Group:
 
Upload Supporting Documents
(DOC or PDF only please):
 
Upon submission, you will receive an email confirmation for your records.
 

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