Online Assignment Form (Type and submit your information below)
Company:
Address:
City, State, Zip:
Phone(s):
Fax:
E-mail address:
Report and bill to (leave blank if same as above):
Your Name:
Insured:
Location:
DOL:
Policy:
Claim #:
PCI File #:
Insured Contact Number:
Instructions: (Check all that apply) O&C Expert Witness Other
Additional Comments:
You may also print and fax this form to (936) 321-4992, or send it by E-Mail to mchaney444@aol.com
Experience Wins.
Houston: (metro) (936) 321-4989 800-895-8350 Fax: (936) 321-4992 5497 Teas Nursery Road, Conroe, Texas 77304