Assign a New Claim

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Claim Number *

Date of Loss *

Adjuster Name

Adjuster Phone

Adjuster Email *

Email for the adjuster or claims team assigning this work. The assignment confirmation, including the claim number, will be sent here.

Insurance Company

Additional Confirmation Email

Optional: enter a different email address for the submitter or claims-team mailbox that should also receive the assignment confirmation. Leave blank if only the adjuster needs a copy.

Insured's Name

First

Last

Claimant's Name

First

Last

Phone *

Vehicle Owner / Inspection Contact Email

Email for the vehicle owner or person coordinating the inspection. Assignment confirmations are sent to the Adjuster Email and any Additional Confirmation Email provided.

Address

Address Line 1

Address Line 2

City

— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Inspection Location

Vehicle Year

Vehicle Make

Vehicle Model

Vehicle Color

Vehicle Identification Number (VIN)

Vehicle License Plate #

Any Special Instructions

File Upload

Drag & Drop Files, Choose Files to Upload

Checkboxes

• I Agree to Marketing Emails from Complete Claims Service (optional)

Submit

We at Complete Claims also allow claim submissions through email. You may send your claim to admin@completeclaims.com. You can also call or fax the office directly.

Telephone: 516-935-8780
Fax: 516-939-0520