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Workers' Comp Assignment Form

Please complete and submit the following information regarding your workers' compensation 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.
 
* I acknowledge the form is completed.

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