Fax Assignment Form

Your Name: ______________________________
Company: ________________________________
Address: _________________________________
City, State, Zip: ____________________________
Phone(s): _________________________________
Fax: _____________________________________
E-mail address: _____________________________

Report & bill to (leave blank if same as above):
Name: ____________________________________
Company: ________________________________
Address: _________________________________
City, State, Zip: ____________________________
Phone(s): _________________________________
Fax: _____________________________________
E-mail address: _____________________________

Insured: ___________________________________
Location: __________________________________
DOL: _____________________________________
Policy #: ___________________________________
Claim #: ___________________________________
PCI File # (for our use--leave blank): _____________

Contact phone number for insured: ___________________________

Instructions: (   ) O&C       (   ) Expert witness          (   ) Other (explain below)
______________________________________________________________
______________________________________________________________
______________________________________________________________

Comments: _____________________________________________________
______________________________________________________________
______________________________________________________________

Please fax to (936) 321-4992

Experience Wins.

Houston: (metro) (936) 321-4989 • 800-895-8350 • Fax: (936) 321-4992
5497 Teas Nursery Road, Conroe, Texas 77304

*Cut and paste the above information and E-Mail: mchaney444@aol.com or Fax the form.