413-586-7227

Amherst Appraisal, Inc.
245 Russell St. - Unit 17
The Madison Building
Hadley Park Plaza
Hadley, MA 01035-9558

Telephone: (413) 586-7227
Toll-Free: (800) 428-2188
Fax: (413) 586-8514
office@amherstappraisal.com

Loss Assignment Form

Today's Date: -- mm/dd/yy

Insurance Company:

Insurance Company Tel#:

Agent:

Agent Tel#:

Assigned By:

Tel# + Ext.

Type: Road Assignment Drive-In

Email Address:

Claim Number:

Policy Number:

Date of Loss: -- mm/dd/yy

Insured's Name:

Claimant Name (if applicable):

Address:

City:

State: Zip:

Owner's Home Phone:

Owner's Work Phone:

Year: Make:

Model:

Color:

License Plate #:

VIN#:

Type of Loss:

Location of Vehicle:

Description of Damage: