Johnson, Cambra & Libbert
Assignment Form
If you do not wish to use this online form, please download the PDF version of the form, which you can then print, fill out, and fax to the nearest JC&L office.

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Claim Information
Send this Assignment Form to:
Assignment Date:
Insured or Claimant:
Date(s) of Loss:
Loss Location:
Date Repairs Completed:
 (Check box if repairs were not completed.)

Claim, Policy, or File Number:
Amount(s) Claimed:
Event Giving Rise to Claim:
Service Requested of JC&L:
Names, titles, and telephone numbers of Contact Persons at Insured, Claimant's, Plaintiff's, and/or Defendant's office:
Coverage Considerations:
Coinsurance:
Extended Period of Indemnity (# of days)
Deductible:
Client Contact:
Adjuster or Attorney Name:
Adjuster or Attorney Telephone and FAX numbers: PHONE: FAX:
E-mail Address
Company Name
Bill to Address
Miscellaneous Information & Comments
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