The National Association of Independent Insurance Adjusters

Casualty Claim Submission

Submit claim to the following NAIIA Member:

Select NAIIA Member

Claim Details and Assignment Type

* DOL(mm/dd/yyyy)

/ /

* Claim #

Policy #

* Claim Type

Auto Liability
General Liability
Workmans Comp

* Description of Loss

* Assignment Type

Limited Assignment
Full Assignment

* General Assignment Instructions

Special Instructions for Statements / Interviews

	Do Not Contact	Interview Only	Recorded Statement	Written Statement	Include Summary	In Person	On Phone
Insured
Claimant
Witnesses

Client Information/Reporting Address

* Client Company Name

* First Name

* Last Name

* Mailing Address

Building/Suite

* City

* State

* Zip

* E-Mail Address

* Phone #

Fax #

Insured Name and Contact Information:

* Insured First Name

Middle

* Last Name

Company Name

Address 1

Address 2

City

State

Zip

* Phone #

Other Phone #

Fax #

Instructions/Other Information Regarding Insured

Claimant Information - Primary

* Claimant First Name

Middle

* Last Name

Company Name

Address 1

Address 2

City

State

Zip

* Phone #

Other Phone #

Fax #

Instructions/Other Information Regarding The Primary Claimant