Correa Claims Service

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ASSIGNMENT REQUEST

Correa Claims Service
P.O. Box 474
Brea, California 92822
Tel: 714- 671-4936 • Fax: 714-671-4959

ASSIGNMENT INFORMATION:
Date:
From:
Street :
Street 2:
City:
State/Province:
Zip Code:
Phone:
Fax:
Adjuster:
Ext:
Claim #:
DOL:
Deductible:
Type of Loss:	COLL PD COMP No Coverage Other
Insured:
Owner:	Insured Claimant:
Street :
Street 2:
City:
State/Province:
Zip Code:
Home:
Work:
Cell:
Location:	HOME WORK SHOP TOW OTHER
Street :
Street 2:
City:
State/Province:
Zip Code:
Phone:
Contact:
Vehicle Description:
Year:
Make:
Model:
Color:
License:
VIN #:
Area of Damage:
Loss Details:
Special Instructions:

Correa Claims Service
P.O. Box 474
Brea, California 92822
Tel: 714- 671-4936 • Fax: 714-671-4959