New Loss Assignment Form

Contacting White and Williams LLP through the use of this e-mail form does not create an attorney-client relationship with the firm or any of the firm's attorneys. You should not send information of a confidential nature to us until you speak to an attorney and have established a privileged relationship with our firm. If you are not currently a client of White and Williams LLP, this message may not be protected under the attorney-client privilege. The invitation to contact the firm is not a solicitation to provide professional services or create an attorney-client relationship, and it should not be construed as a statement as to the availability of any of our attorneys to perform legal services in any jurisdiction in which such attorney is not permitted to practice. By completing this form and clicking the "Submit" button below, you indicate your agreement to these terms.

Date of Assignment

Carrier

Referrer/Phone Number

Subrogation Contact

E-Mail for Subrogation Contact*

Phone Number for Subrogation Contact

Insured*

Insured Contact/Phone Number

Date of Loss*

Claim Number*

Loss Location*

Approximate Amount of Loss

Company Adjuster/Phone Number

Basic Facts

Expert Status

Site Status

Special Comments

Report To

Name/Address of Potentially Adverse Party

X Code

* Indicates a required field.

New Loss Assignment Form

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