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
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