Jim Buckley and Associates, Inc
Insurance Adjusters

Assignment

Please email your assignment instructions and/or documentation to [email protected] or fill out the form below

Please Fill out the form

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
Email
This field is for validation purposes and should be left unchanged.