New Claim Assignment

Thank you for choosing Millennium Claims Services! You may email your assignment to assignments@millenniumclaims.com, or use the form below. Our team is standing by!

Submitter Name *

Submitter Company Name *

Submitter Phone Number *

Submitter Email *

Policy Information

Insured Name *

Layout

Policy # *

Start *

End *

Coverage Line *

Coverage Type *

Coinsurance %

Deductible

Add Coverage Line #2

Check to Add

Add Coverage Line #3

Check to Add

Add Coverage Line #4

Check to Add

Loss Information

Claim Number *

Loss Date

Loss Type *

Brief Description of Loss

Loss Location *

Address Line 1

Address Line 2

City

State

Zip Code

Primary Contact Name *

Primary Contact Number *

Is there an alternate Contact?

Check box if Yes

Instructions and Documents

Special Instructions

Valuation Required *

Attachments

Policy
NOL
Other

How many files would you like to upload?

Website

Policy Information

Loss Information

Instructions and Documents

Questions? Comments?

Phone