Liability Assignment Form

*Note: All fields marked with an asterisk (*) are required.
Adjuster NameInsurance CompanyMailing AddressBuilding/SuiteCityStateZipPhone NumberFax NumberEmail AddressDOLClaim NumberPolicy NumberFirst NameLast NameMailing AddressBuilding/SuiteCityStateZipHome PhoneCell PhoneWork PhoneFax NumberEmail AddressLoss LocationAccident DescriptionFirst NameLast NameMailing AddressBuilding/SuiteCityStateZipPhone NumberFax NumberEmail AddressWitness NameWitness Phone NumberOther Special InstructionsDo you want us to take a recorded statement?
If so, who?Scene investigation?
Obtain police report?
Police DepartmentCase NumberAuto Appraisal?
Which vehicle?Is the vehicle a total loss?
Total loss instructionsCCC, ADP, or get dealer quotes?

Do you want us to move salvage?
If so, where to? NameMailing AddressBuilding/SuiteCityStateZipPhone numberHow do you prefer we return assignments to you?

Attachment 1Attachment 2Attachment 3

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*Contact Email
Intermountain Service Areas

Idaho Service Area
We provide WC and P&C services throughout all of Idaho

Montana Service Area
We provide WC services throughout all of Montana and P&C services in Missoula and the surrounding areas

Oregon Service Area
We provide WC and P&C services in Portland, E. Oregon, and the surrounding areas

Utah Service Area
We provide WC and P&C services throughout all of Utah

Washington Service Area
We provide WC services throughout all of Washington and P&C services in Yakima, E. Washington, and the surrounding areas

See the Area Map of our service coverage.