Jim Buckley and Associates, Inc
Insurance Adjusters

Assignment

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Date Assigned
Date Format: MM slash DD slash YYYY
Client/Adjuster*
Client's Email*
Client's Phone*
Client's Claim Number
Coverage Information
Coverage Amounts
A B C D Other
Deductible
Forms/Endorsement(s)
Policy Number
Effective Date
Date Format: MM slash DD slash YYYY
Insured
Name
Contact
Address
Phone
Claimant
Name
Contact
Address
Phone
Loss Information
Date of Loss
Date Format: MM slash DD slash YYYY
Location of Loss
Type of Loss
Description of Loss
Instructions
Attach File
Drop files here or
Name
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