Forms | CCR Adjusters

CCR Assignment forms can be filled out and submitted directly online by proceeding below.

If you would prefer to use your own form please email it as a pdf attachment to claims@ccradjusters.com or simply include the contents in the body of the email. Additionally you may fax your form to us at 860-496-8581.

Loss Assignment Form

Fields marked with a * are required

Please fill in applicable information regarding your assignment and submit to CCR Adjusters

Client Name *

Client Address *

Client City *

Client State *

Client Zipcode *

Adjuster Information

Adjuster *

Phone *

Phone Ext

Fax Number

Email Address *

Claim Number *

Insured Information

First Name *

Last Name *

Address 1 *

Address 2

City *

Zip / Post Code *

Phone *

Loss and Policy Information

Loss Date *

Loss Location *

Loss Description: *

Policy Number: *

Coverage Limits:(Cov A, B, C, D) *

Effective Date: *

Expiration Date: *

Deductible: *

Mortgagee(s): *

Claimant Information

Claimant Address

Claimant Home Phone:

Claimant Work Phone:

Ext:

Services Requested

Services (Hold down ctrl key to select multiple)

Other Services

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