CLIFFORD S. TROTTER ASSOCIATES 
INVESTIGATIONS
631-467-4966

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Carrier / Attorney Assignment

INSURANCE CARRIER/LEGAL COUNSEL ASSIGNMENT

PLEASE SUPPLY AS MUCH INFORMATION AS POSSIBLE IN THE FIELDS BELOW.  WE REQUEST THAT YOU SEND ANY SUPPORTING PAPERWORK SUCH AS ACCIDENT REPORTS, ETC., EITHER VIA FAX TO 631-467-1167, OR SCANNED AND E-MAILED TO clientservices@cstrotter.com
WE WILL ACKNOWLEDGE RECEIPT OF THIS ASSIGNMENT BY E-MAIL OR BY TELEPHONE ON THE NEXT BUSINESS DAY FOLLOWING RECEIPT.
THANK YOU FOR YOUR SUPPORT.

Insurance Carrier:
Carrier Claim Number:
Legal File Number:
Claim Examiner:
Address:
Telephone Number:
E-Mail Address:
Insured's Name:
Insured's Address:
Incident Location:
Contact Person:
Contact Phone Number(s):
Claimant's Name:
Accident /Incident Date:
Type of Accident:
Accident/Incident Details:
  Scene Photographs
  Scene Diagram
  Witness Statement
Witness (Name/Address/Phone):
Witness (Name/Address/Phone):
Legal Counsel:
Counsel's Address:
Attorney Assigned:
Assignment Details:

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