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ICS Online Assignment Request Form
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Insurance Company
*
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Indiana Farm Bureau
Auto Owners, Indiana Regional
Auto Owners, Indianapolis
Auto Owners, Louisville
Auto Owners, Mishawaka
Auto Owners, New Albany
Auto Owners, Sweetser
Auto Owners, Adrian
Auto Owners, Appleton, WI
Auto Owners, Clarkston
Auto Owners, Clearwater, FL
Auto Owners, Dayton
Auto Owners, Gran Rapids, MI
Auto Owners, Lansing
Auto Owners, Lexington
Auto Owners, LIMA
Auto Owners, Miamisburg
Auto Owners, Motor Carrier
Auto Owners, Mt. Pleasent
Auto Owners, Mt. Vernon
Auto Owners, Ocala, FL
Auto Owners, Portage
Auto Owners, St. Joseph, MI
Auto Owners, St. Paul, MN
Auto Owners, Stuart, FL
Auto Owners, Toledo
InsureMax
Erie Insurance
ESIS
ESIS GM
Indiana Farmers
LMAM
LMAM - HE
North American Risk Services
Other
Philadelphia Insurance
Protective Insurance
Sagamore
Secura Insurance
State Auto
Syndicate Claims Service
United Fire Group
Other:
Override Company
CL
PL
Claim #
*
Date of Loss
*
+
Adjuster Information
First Name
*
Last Name
*
Phone Number
Ext.
Email Address
Insured
*
Deductible
Assignment For?
*
Insured
Claimant
Owner Information
First Name
Last Name / Business Name
*
Street Address
City
State
Zip Code
Home Phone
Cell Phone
Work Phone
Ext.
Vehicle Information
Year
Make
Model
Color
VIN
Plate
Unit # (
If applicable
)
Loss Type?
*
Collision
Comprehensive
Other
Explain
Comprehensive
Deer/Animal Hit
Fire - Complete Burn
Fire - Electrical
Water/Flood
Hail
Wind/Debris
Overspray
Mechanical
Vandalism
Additional information
Primary Impact
Front
Right Front
Left Front
Right Side
Left Side
Rear
Right Rear
Left Rear
Driver Side Back
Passenger Side Front
Passenger Side Center
Passenger Side Back
Rollover
Secondary impact?
Yes
No
Secondary Impact
Front
Right Front
Left Front
Right Side
Left Side
Rear
Right Rear
Left Rear
Driver Side Back
Passenger Side Front
Passenger Side Center
Passenger Side Back
Rollover
Vehicle Location
Is the vehicle drivable?
Yes
No
If repairable, ok to release estimate?
Yes
No
Add another vehicle?
Yes
No
Year
Make
Model
Color
VIN
Plate
Unit # (
If applicable
)
Add another vehicle?
Yes
No
Year
Make
Model
Color
VIN
Plate
Unit # (
If applicable
)
Add another vehicle?
Yes
No
Year
Make
Model
Color
VIN
Plate
Unit # (
If applicable
)
Assignment Notes
Attach any additional documentation (up to 5)
*
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*
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