Property Damage Appraisal Assignment Information Form

This Property Damage Appraisal Assignment Form is for use by claim adjusters, and can be used to assign Property Damage appraisals for ALL TYPES of damage loss, including Theft, Fire, Wind, Vandalism, or Other. When the form has been submitted, it will be forwarded directly to Auto Damage Appraisers Houston.

File No.:
Policy No.:
Company:

POLICY TYPE: Property/Homeowners Flood Wind Other
POLICY EFFECTIVE DATE:
POLICY EXPIRATION DATE:
Date of Loss: (MM/DD/YY)
WHAT KIND OF LOSS OCCURED: Fire Theft Lightning Hail Flood Wind Other

Does the property have a mortgage : Yes No
What is the name and address of the mortgagee :
Mortgagee Name:
Address (line 1):
Address (line 2):
City: State/Province: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming --------------- Alberta British Columbia Manitoba New Brunswick Newfoundland Nova Scotia Ontario Prince Edward Island Quebec Saskatchewan
Zip Code:
Country:
Phone:

Please indicate applicable coverage limits:
A.Dwelling B.Other Structures
C.Property D.Loss of Use Deductions
Please describe any additional coverages provided under the policy :

Please describe any exclusions or coverage modifications :

Please identify any other insurance on this property including carriers, policy, numbers, coverages and policy amounts :

Insured:
Address (line 1):
Address (line 2):
City: State/Province: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming --------------- Alberta British Columbia Manitoba New Brunswick Newfoundland Nova Scotia Ontario Prince Edward Island Quebec Saskatchewan
Zip Code:
Country:
Home Phone: Bus. Phone:

What is the estimated value of the damages or loss :

Deductible: $
Loss Description:

Special Instructions:

Obtain Agreed Price With Repair Contractor?
Appraise Damage Only. Do Not Obtain Agreed Price
Other
Photos: 1 To Document Damage As Needed To Document Damage
Photo Format: 35mm Only Digital Other

Call Back Instructions
Call Back To: Adjuster Other