Industrial Loss Consultants Online Desk Review Form

New Assignment Form

Insurance Company

* Indicates Required Fields.
If the required information is unknown, please input XXXXX in the highlighted field.

* Indicates required field

Company Name *

Adjuster *

Address:

Address Line 1 *

Address Line 2 *

City *

State *

Zip Code *

- *

Billing address is same as above

Bill To:

Address Line 1 *

Address Line 2 *

City *

State *

Zip Code *

Office Number *

Mobile Number *

Email *

Claim Number *

Date Of Loss *

Type Of Loss *

Insured

Company Name *

Insured Product Line *

Claim Location:

Address Line 1 *

Address Line 2 *

City *

State *

Zip Code *

Contact Name *

First

Last

Phone Number *

Email *

RCV *

Yes No

ACV *

Yes No

Fair Market/Used *

Yes No

Instructions *

Upload File *

Max file size: 20MB

Upload File *

Max file size: 20MB

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If the required information is unknown, please put XXXXX in the highlighted red field.
You can always call 1-800-497-4030 for assistance – Thank you.

Submit

New Assignment Form

Insurance Company

Address:

Bill To:

Insured

Claim Location:

Industrial Loss Consultants Inc

About Us

Events

Services Provided

Our Process

Area Of Expertise

Types Of Losses

Who We Serve

New Assignment Form

Insurance Company

Address:

Bill To:

Insured

Claim Location:

Industrial Loss Consultants Inc

About Us

Events

​Services Provided

Our Process

Area Of Expertise

Types Of Losses

Who We Serve

Services Provided