ASSIGN A CASE

Insurance Investigation

Private Investigation


If you are serious about your results, we are your finest choice.




FULLY-LICENSED

Submit New Insurance Claims Handling Assignment

If you do not wish to use this form, you can just email your own assignment form to us instead. Be advised that our forms are typically much more detailed than standard Acord forms.
* The more information you provide, the better we can achieve your objectives *

Your Information
Bill to

,

,

,

City , State Zip

Phone , Xt # , Fax , Cell , Email


Loss Information

UNIT:

Automobile Cargo Commercial Auto Commercial General Liability Commercial Property
Commercial Truck Entertainment Homeowner Liability Homeowner Property Inland Marine
Jewelers Block Ocean Marine Professional Liability Renters Insurance Workers Comp


Named Insured Information

, , ,

, Unit#

City , State Zip

Phone , Xt # , Fax , Cell , Email

Vehicle Information (if appl.):

, , , , License Plate #

VIN Type of Vehicle

Driver Information (if appl/different from named insured.):

, , ,

, Unit#

City , State Zip

Phone , Xt # , Fax , Cell , Email



Claimant Information

, , ,

, Unit#

City , State Zip

Phone , Xt # , Fax , Cell , Email

Vehicle Information (if appl.):

, , , , License Plate #

VIN Type of Vehicle

Insurance Information (if appl.):

, , Suite#

City , State Zip

Phone , Xt # , Fax , Cell , Email

Adjuster Policy# Claim#



Witness Information

, , ,

, Unit#

City , State Zip

Phone , Xt # , Fax , Cell , Email



Services Requested


Arbitration/MSC/Mediation Court Check Depreciation Schedule Determine ACV
Determine RCV Diagram Preparation Prepare Xactimate Estimate Property Investigation
Scope of Damages Witness Canvassing Other Activity


Affidavit of No Other Assets Affidavit of No Other Insurance Affidavit to Release Policy Limits
Agent's Policy File Building Permits/Plans Coroner's Report Death Certificate Fire Report
Housing Violations Medical Authorization Medical Reports Nonwaiver Agreement Notarization
Police Report Trucker's Checklist Wage Authorization Other Documents


Photographs Only Video Only Both Photographs and Video Photos + Damage Appraisal
Claimant Vehicle Injuries Insured Vehicle Property Damage Scene Investigation Other


Agent Claimant Insured Witness Other Statement

Yes No

Yes No



Cc Report to (if appl)
Bill to

,

,

,

City , State Zip

Phone , Xt # , Fax , Cell , Email


* Finalize *

Click the Print button and "change" printer type to Save as PDF option. Save the PDF of your completed request in your case file, then email the new assignment as a PDF attachment from your hard drive. If you don't have a PDF printer option, you can simply print out a paper copy and submit the request by fax.


"We appreciate your business!"

Note: If you need private investigation work (process service, skip-trace, sub-rosa, etc.), click here.


J. Koerner Investigations
P.O. Box 4186
San Dimas, CA 91773
Tel: (909) 225-5448
Fax: (909) 267-9760