Pelto Group – Claim Investigation Assignment Form

Please complete the fields below for each assignment and press SUBMIT. Note: All fields are required. Insert N/A or UNK if UNKNOWN

Date:
12/17/2017
Your Company’s Name:
 
Your Name:
 
Your Phone Number:
 
Your Email Address:
Your claim number or other reference:
 
Date of loss:
 
Time of loss:
 
Location of loss: (road/city/State)
 
Line of coverage:
 
Brief loss description:
 
Person to be contacted:
Name #1:
 
Party type:
 
Address:
 
Phone:
 
Name #2:
 
Party type:
 
Address:
 
Phone:
 
Service Desired:
 
Additional Detail: