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 have not been 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:
Waiting Period (# of days):
Coinsurance:
Ordinary Payroll Covered (# of days)
Extended Period of Indemnity (# of days)
Deductible:
Client Contact:
Adjuster or Attorney Name:
Adjuster or Attorney Telephone numbers: PHONE:
Adjuster or Attorney FAX number: FAX:
E-mail Address
Company Name
Bill to Address
Miscellaneous Information & Comments
If you do not receive an acknowledgement from us within one business day, please call.
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