ClaimSolution Assignments

ClaimSolution Inc
8900 Indian Creek Parkway Suite 450
Shawnee Mission KS 66210
(913) 322-2300

Vehicle Online Assignment Form

Privacy Policy

ClaimSolution, Inc. will use your email address only for claims.
We will never sell or make your information available for any other purpose.

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Your Email Address:*

Your Full Name:*

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Company Name:*

Mailing Address:*

City:*

State:*

ZIP Code:*

Main Phone:*

Main Fax:*

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First Name:*
Last Name:*
Phone:*
Fax:*
Email:*

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First Name:*
Last Name:*
Phone:*
Fax:*
Email:*

Claim Category:*
Claim Type:*
Claim Number:*
Policy Number:*
Date of Loss:*
Deductible Amount:*

Claim Notes:*

Owner Type:*

First Name / Company:*

Last Name:*

Address:*

City:*

State:*

ZIP Code:*

Phone:*

Email:*

Insured Full Name:*

VIN:*
Make:*
Model:*
Year:*
Color:*
License Plate:*
License State:*
Is Vehicle Drivable:*
Damage Description:*
Damage Notes:*

Full Name / Company:*

Address:*

City:*

State:*

ZIP Code:*

Phone:*

Email:*

Location Remarks:*