New Loss Assignment Form

Please complete the form below and submit via our secure server.

  • Reboul & Henderson guarantees a prompt response to receipt of this online form.
  • We will contact the Insured or Claimant as soon as possible.
  • This method of loss assignment is optional; we also accept assignments by telephone, fax or mail.

PDF version of this form also available

Required Information
Please feel free to include all your pertinent New Loss information in this form. Or, if you'd prefer, simply fill out these two fields, and skip to the bottom of the form to submit. We'll be in contact with you promptly!
Your Name
  •  
Primary Phone --
  •  
File Identification
Insured
  •  
D / B / A
  •  
Claimant
  •  
Address
  •  
Email Address
  •  
Claim #
  •  
File #
  •  
Date of Loss //
  •  
Client Information
Client Name
  •  
Company
  •  
Please update the Client Information fields below if it's new or has changed; if we have already have your current information you may skip the next 8 fields and move on to Loss Contact Information.
Mailing Address
  •  
Phone # --
  •  
Email Address
  •  
Loss Contact Information
Loss Contact
  •  
Job Title / Position
  •  
Phone # --
  •  
Address
  •  
Secondary Loss Contact
  •  
Job Title / Position
  •  
Phone # --
  •  
Loss Information
Type of Claim
  •  
Date Loss Period Ends //
  •  
Scope
  •  
Additional Comments
  •  
Coverage
Limit
  •  
Waiting Period
  •  
 Hours
  •  
 Days
Extended Period of Indemnity
  •  
 Days
Co-Insurance: Contribution %
  •  
Other
  •  
  •