Date Submitted---------------------
Submitted By------------------------
Claim Number-----------------------
Insurance Company---------------
Insured Name------------------------
Date of Loss-------------------------
Owner Name-------------------------
Owner Address line 1-------------
Owner Address line 2-------------
Owner Phone #---------------------
Vehicle Year, Make & Model--
Damages------------------------------
Coverage------------------------------
Deductible----------------------------
Vehicle Location
Notes or Special Handling
Your Phone # 
Your Email Address
Veh Vin #-----------------------------
ICS Assignment Form