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Assign a Claim

Online Submission Form

New Assignment Form

Fill out the form below to assign a claim. One of our claims representatives will be in touch within one business day.

    (Fields marked with * are required)

    Customer Information

    First Name*

    Last Name*

    Title

    Company*

    Address*

    City*

    State*

    Zip*

    Phone*

    Fax

    Email Address*

    Your Claim #*

    Date of Accident/Loss*

    Insured

    Insured Type

    Insured First Name

    Insured Last Name*

    Address

    City

    State

    Zip

    Phone

    Email

    Claimant

    Claimant Type

    Claimant First Name

    Claimant Last Name

    Address

    City

    State

    Zip

    Phone

    Email

    Assignment

    Type of Assignment*

    Loss Description*

    Assignment (What do you want MAS Solutions to do?)*

    Assignment Location

    Address*

    City*

    State*

    Zip*

    Injury / Damage / Coverage

    Injury / Damage

    Coverage Information

    Attachments

    Individual file size may not exceed 10MB