Florida Claims Specialists, Inc.

New Assigment
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Client Info.



Date        

Client       

Requester 

Phone          E-MAIL 

Mailing Address *Required For First Assignment

City               State   Zip

Insured     

Claim#       

Date Of Loss


Claimant - Subject

Name                 

Mailing Address 

City State ZIP

DOB        Height Sex   Hair   Race

Weight      SSN   

Distinguishing Features 

Occupation   Employer

Address         City

          State   Zip       Phone# 

Vehicle(s)

Year Make Style Color Tag State


Year Make Style Color Tag State

Investigation / Specific Requests

Nature.Of.Injuries

Physician

Attorney 


Assignment Instructions


Budget Maximum

Any specific dates or days of the week you would like this done?