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B.I.S. Assignment Form

 

Please fill in the form below in full, then click "Submit" to submit your request.

 

 

 

Contact Information      
Date of Request: Requester:
Company: Office Location:
Telephone: Fax:
Email: Principle (if applicable):
Claim No: Policy No:
Insured:    
       
Claimant/Subject Information      
Surname: Given Name (1):
Given Name (2) : Date Of Birth:
Gender:  
Primary Address: Secondary Address:
Residential Telephone: Celluar Telephone:
Drivers Licence No: Claimant/Subject Description:
Marital Status: Spouse's Name:
Children / Ages:  
 
Vehicle Information      
Accident Vehicle (year/make/model): Licence Plate:
Write Off?
 
 		 Other Vehicles
(year/make/model):
    License Plate of other vehicles:
       
Employment Info      
Employer: Employer's Address:
Employer's Telephone: Occupation:
Comments / Remarks:  
       
Claim Information      
Date of Loss : Type of Claim:
If it is an Accident Benefit Claim, please check the following:
IRB Claim Caregiving Claim House Keeper Claim  
Stated Injuries :
Nature of Claim :
       
Associated Persons & Locations      
Lawyer: Address:
Telephone:
Doctor: Address:
Telephone:  
Physio/Rehab Address:
Telephone:  
Chiropractor: Address:
Telephone:  
Other: Address:
Telephone:  
 
Type of Investigation      
Select Type of Investigation :
Specific days or dates:
Comments/Instructions:

 

 

 
Budget:

 

 

 

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