Lightning Verification Assignment Form

Your Information

First Name

Last Name

E-mail

Only fill out the address and contact numbers if:
You are a NEW CLIENT
OR
you have a CHANGE
Company

Address - Physical

Address - Mailing

Telephone Ext.

Fax

Mobile

Insured's Information

Insured's name

ID type      ID number

Address

Home

Work                   Ext.

Mobile

Loss Date           Loss Amount          Loss Time

Equipment Information

Site visit examination
Laboratory examination (This is the normal examination type)
     Pick-up Method


Yes - Pick-up location different from insured's
No - advance to "List all damaged equipment"

Equipment location (Co. and address)

Pick-up Contact

Pick-up telephone numbers

List all damaged equipment

Special Instructions

Pick-up date

Permission to use courier/wrecker in addition
     to trucking company if necessary.
Must contact you for courier/wrecker use.

Report Submission

Submit report to another person
Submit to:(Name, Co., Address, e-mail, and telephone)

Report to be received via

This marketing introduction describes some of our expertise. For more information, comments or questions, please contact us. 1.866.451.5438, contact form, or office@aceForensics.com