Date of Loss

Contact Information

Insureds Information

Billing Information

Please complete this section if billing information differs from the contact information above.

File Information

Please provide any special instructions and job request details in this section.


If evidence is being sent in conjunction with this assignment, please complete the following fields.

Submission of evidence with this form, is an agreement between the submitting party named as the primary contact and JENSEN HUGHES that any such evidence is covered by the JENSEN HUGHES Evidence Storage Agreement and Liability Statement which is available upon request.

If you would like to speak to someone immediately you may reach us by calling 1.800.711.0704

If you do not receive an email confirmation with the hour, please contact us directly by calling 1.800.711.0704