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Texas Non-Subscriber Assignment Form

Please complete and submit the following information regarding your Texas non-subscriber 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:*
E-Mail:*
Company Name:*
Street Address:*
Street Address (cont):
City:*
State / Province:*
Zip / Postal code:*
Phone:*
Fax:
Mobile:

Coverage
Coverage Confirmed?

Loss Information
Date of Accident:* (MM/DD/YYYY)
Customer Claim #:
Location of Accident:
Brief Description of Accident:*

Employer Information
Employer/Insured:*
Date Accident Reported
to Employer:*		 (MM/DD/YYYY)
Contact First Name:
Contact Last Name:
Employer Address:
Employer Address (cont):
City:
State/Province:
Zip/Postal Code:
Employer Work Phone:

Claimant Information
Claimant First Name:
Claimant Last Name:
Gender:
Claimant Address:
Claimant Address (cont):
City:
State / Province:
Zip/Postal Code:
Claimant Home Phone:
Claimant Work Phone:
Claimant Mobile Phone:
Occupation:

Investigation Type:
Action(s) to take / 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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