Assign a Claim

Online Submission Form

New Assignment Form

Fill out the form below to assign a claim. One of our claims representatives will be in touch with you in 24 hours.

    (Fields marked with * are required)

    Customer Information

    First Name*
    Last Name*
    Title
    Company*
    Address*
    City*
    State*
    Zip*
    Phone*
    Fax
    Email Address*
    Your Claim #*
    Date of Accident/Loss*

    Insured

    Insured Type
    Insured First Name
    Insured Last Name*
    Address
    City
    State
    Zip
    Phone
    Email

    Claimant

    Claimant Type
    Claimant First Name
    Claimant Last Name
    Address
    City
    State
    Zip
    Phone
    Email

    Assignment

    Type of Assignment*

    Loss Description*
    Assignment (What do you want MAS Solutions to do?)*
    Assignment Location
    Address*
    City*
    State*
    Zip*

    Injury / Damage / Coverage

    Injury / Damage
    Coverage Information

    Attachments

    Individual file size may not exceed 10MB