Assignment Form

@if ($errors->any())

{{ $error }}

@endif

Claim Information

@if (session()->has('message'))

@endif

Insurance Company *

@if (session()->has('adjuster_search')) {{ session('adjuster_search') }} @endif

Claim Number *

Policy Number *

Deductible Amount

Claim For

Date of Loss *

Type of Loss *

Service Requested *

Unit Type *

Insured Name

Type of Loss Description

Collision - This is dealing with an automobile.

Commercial Property - This is real property - real estate.

Comprehensive - This is dealing with an automobile.

Liability/PD - This is dealing with an automobile.

Other - This is dealing with an automobile.

Residential Property - This is real property - real estate.

Adjuster Information

First name *

Last name *

Email Address *

Phone Number *

Owner Information

Business Name

First Name *

Last Name *

Email Address

Phone Number

FAX Number

Contact Name

Address @error('business_street')

@enderror

City *

State *

Postcode *

Vehicle Location

Location Name

Location Phone

Address @error('vehicle_street')

@enderror

City

State

Postcode

Vehicle Information

VIN @error('vehicle_vin')

@enderror @if (session()->has('vin_decoded')) {{ session()->get('vin_decoded') }} @endif

Decode

Year

Make

Model

License Plate

Color

Mileage

Damage

Instructions *

Attachment Files @error('newfileattach.*')

@enderror @if ($newfileattach)

@foreach ($newfileattach as $index => $file)

{{ $file->getClientOriginalName() }} ({{ number_format($file->getSize() / 1024, 2) }} KB)

@endforeach

@endif

Assignment Form

Claim Information

Type of Loss Description

Adjuster Information

Owner Information

Vehicle Location Same As Above

Vehicle Information

Vehicle Location