Assignment Sheet – Serafin Investigations

P.O. Box 185
Avon-by-the-Sea, NJ, 07717
732-946-3100
732-946-8474 fax

		
		
		
Insured Information
Named Insured * 
First Last
Claim Number * 
Date of Loss * 

Company Information
Company Name 
Company E-mail 
Company Phone - 
Area Code Phone Number
Company Fax - 
Area Code Phone Number
Company Address Street AddressStreet Address Line 2CityState / Province / RegionPostal / Zip CodeCountry
Send Report  'Attention to'  . * 
Send Using Email
Fax
Regular Mail
1/5 

Claimant Information
Claimant Name 
First Last
Social Security Number 
Date of Birth 
Drivers License Number 
Drivers License State 
Claimant Home Phone - 
Area Code Phone Number
Claimant Work Phone - 
Area Code Phone Number
Claimant Cell Phone - 
Area Code Phone Number
Claimant Address Street AddressStreet Address Line 2CityState / Province / RegionPostal / Zip CodeCountry
2/5 
Insured Information
Insured Name 
First Last
Insured Home Phone - 
Area Code Phone Number
Insured Work Phone - 
Area Code Phone Number
Insured Cell Phone - 
Area Code Phone Number
Insured Address Street AddressStreet Address Line 2CityState / Province / RegionPostal / Zip CodeCountry
3/5 

Services Needed
Select Services Full Investigation
Attempt to Locate
General Liability
Computer Searches
Workers Comp Investigation
Adjustment
Photo Auto/Claimant
Photo Auto/Insured
Product
Surveillance
Residency Check
Witness Canvas
Background Investigation
Video Tape
Prior Injury Investigation
Uninsured Motorist - Check Coverage & Assets
Uninsured Motorist - Check Assets
PIP Eligibility Investigation
Photos - Scene and Diagram
Statement - Insured(s) 
Statement - Claimant(s) 
Statement - Witness(s) 
Statement - Police Officer  . 
DMV Check 
Records 
Other 
4/5 
Special Investigations / Comments
Coments  . 
Upload Documents & Photos
File 1 
File 2 
File 3 
File 4 
File 5 
Submit Claim
Word Verification: 
type_submit_reset_7 
5/5
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