Fire Cause and Origin Assignment Form

FIRE CAUSE AND ORIGIN ASSIGNMENT FORM

COMPANY INFORMATION
Company's Name
Your Name:
Telephone & Extension
E-Mail address:
New Customers Only... Please enter your address. Thanks.
Claim Number:
Policy Number
Date of Accident
Time of Accident

INSURED INFORMATION

Insurance Limit $

Insured:

Address:

City & State:

Tel. #:

DOB:

SSN / Lic No.:

ADDITIONAL INFORMATION

Thank you for assigning an investigation to Claims Bureau New England, Inc.
We will be in touch with you shortly. Bill 800.342.88777