About Assigner

Insurer

Insurer Contact

Client Phone

Insurer Email

Contact's Address

Street Address Address 2 City State ZIP Code

About Assignment

Insured Name

Claim No.

Policy No.

Policy Period

Applicable Policy Forms

Policy Limits

Policy Deductible

How Long has Client Insured the Policy Holder?

Insured's Contact

Position / Title

Insured's Phone

Insured's Email

Insured's Address

Street Address Address Line 2 City State ZIP Code

Loss Location

Is the Loss Location listed on the policy?

Yes
No

Prior Policy Coverage

Excess Coverage

Other Insurance

Date of Discovery

Date Loss Reported

Was POL mailed to insured?

Yes
No

May SDC send POL?

Yes
No

Details of Discovery

Please detail important dates and policy periods using a timeline format below:

Method of Misappropriation

Amount of Misappropriation

Period of Misappropriation

Was Loss Reported to the Police?

Yes
No

Case Number

Police Contact Name

First Last

Phone

Principal's Name

First Last

Job Title

Job Description

Date of Hire

Termination Date

Was Principal Confronted?

Yes
No

Has Principal Confessed?

Yes
No

Any Prior Incidents with the Principal?

Any Monies Owed to Principal For Wages, Holiday, Vacation, etc?

Has Any Restitution Been Paid?

Yes
No

Any 3rd Parties Involved?

Yes
No

Have Banks Been put on Notice?

Yes
No

Date POL Received?

Has Principal Been put on Notice?

Yes
No

SDC File No.

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Email

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Fidelity Form

About Assigner

About Assignment

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