Assign a Claim

Hello world!
February 22, 2016

Assign a Claim

Peninsula Insurance Bureau
6065 NW 167 Street, Suite B1
Miami, Florida 33015
305.824.0111
Fax 305.822.7060
info@pibadjusters.com

To assign a claim to Peninsula Insurance Bureau, please fill out the following form or contact us by phone or email.

Date of Assignment
Company Assigning Loss
Company Address
Company City, State, Zip , ,
Company Phone Number
Company Contact Person
Contact Email
Insured
Insured-Name
Insured-Address
Insured City, State, Zip , ,
Insured Home Phone
Insured Business Phone
Loss
Date of Loss
Type of Loss
Location of Loss
Description of Loss
Policy Information
Policy Number
Policy Effective Dates to
Claim Number
Coverage Information:
Coverage A
Dwelling
Coverage B
Appurtenant Private Structures
Coverage C
Unscheduled Personal Property
Coverage D
Additional Living Expenses
Deductible
Special Instructions

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