Accurate Information Services

ASSIGNMENT SHEET

(please print this form then fax it to 401-427-0292)

Client Information:

Client: __________________________   Assignment Date: ______________________

Address: ________________________    Date of Loss:        ______________________

Adjuster: ________________________   Type of Claim:      ______________________

Phone:     ________________________     Assured:             ______________________

File No:   ________________________      Budget:              ______________________

Subject’s Information:  

Name:  __________________________      SSN: _____________  DOB: ____________

Address:  _______________________      City: ______________  State:  ___ Zip _____

Phone:   __________________   Married  Y    N (circle one)   Spouse Name ___________

Injury:  ___________________________    Restrictions:     _______________________

Physical Description:  _____________________________________________________

________________________________________________________________________  

Additional Information:

Claimant Attorney: ______________________________________________________

Physical Therapist: ______________________________________________________

Appointment/Hearings:___________________________________________________

Objective/Comments: ____________________________________________________

 _______________________________________________________________________