.STS Equipment Restoration LLC

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  INSURANCE CLAIM ASSIGNMENT FORM  
  To assign us a job electronically, fill out this form, and hit the Submit button at the bottom. Even if you don't have all the information, feel free to get started now. Fill in the information you do have, click the Submit button at the bottom of the form, and an STS representative will contact you via phone or e-mail to fill in the blanks.  
  CONTACT INFORMATION  
Name
Company
Address
City
State
Zip
Phone
Fax
E-mail
CLAIM INFORMATION
Carrier Name
File #
Date of Loss
Insured
Address
City
State
Zip
Phone
Fax
E-mail
Claimant/Contact
Address
City
State
Zip
Phone
Loss Location
(if different)
City
State
Zip
       
  LOSS INFORMATION  
 
Describe Loss
  
 
Scope of Service
  
 
Other Notes
  
       
  REPORTING INFORMATION  
   
 
Report To
You
  
 
Other
  
 
Name
  
 
Company
  
 
Address
  
 
 
 
City
  
 
State
  
 
Zip
  
   
  INVOICE INFORMATION  
       
 
Invoice To
You
  
 
Other
  
 
Name
  
 
Company
  
 
Address
  
 
 
 
City
  
 
State
  
 
Zip