The National Association of Independent Insurance Adjusters - NAIIA.com

Vehicle Claim Submission

Submit claim to the following NAIIA Member:

Select NAIIA Member

Claim Details and Assignment Type

* DOL(mm/dd/yyyy)

/ /

* Claim / File #

* Policy #

* Description of Loss

* General Assignment Instructions

Client Information/Reporting Address

* Client Company Name

* First Name

* Last Name

* Mailing Address

Building/Suite

* City

* State

* Zip

* E-Mail Address

* Phone #

1+

Fax #

1+

Vehicle #1 Information

Owner of Vehicle #1

Insured

Claimant

First Name

Middle

Last Name

Company Name

Address 1

Address 2

City

State

Zip

Phone #

1+

Fax #

1+

E-Mail

Location / POI / Damage

Instructions / Other Information

* Vehicle Type

* Vehicle Make

* Vehicle Color

* Vehicle Year

* Vehicle Model

* VIN Number

* License Plate

* Drivable?

Yes No