New Assignment

Please fill out this form as completely as possible. This form is not a retainer nor does it obligate C&M Fire Investigations to accept the assignment submitted. You will receive an email confirmation upon our acceptance of the assignment

YOUR Company & Contact Information:

 

Your Name	Mr.  Mrs.  Ms.
Organization
YOUR affiliation	--- Adjuster Independent Adjuster Public Adjuster Risk Manager Claims Rep Attorney Private Party
Street Address
Address (cont.)
City
State/Province	State AL Alabama AK Alaska AZ Arizona AR Arkansas CA California CO Colorado CT Connecticut DE Delaware FL Florida GA Georgia HI Hawaii ID Idaho IL Illinois IN Indiana IA Iowa KS Kansas KY Kentucky LA Louisiana ME Maine MD Maryland MA Massachusetts MI Michigan MN Minnesota MS Mississippi MO Missouri MT Montana NE Nebraska NV Nevada NH New Hampshire NJ New Jersey NM New Mexico NY New York NC North Carolina ND North Dakota OH Ohio OK Oklahoma OR Oregon PA Pennsylvania RI Rhode Island SC South Carolina SD South Dakota TN Tennessee TX Texas UT Utah VT Vermont VA Virginia WA Washington DC Washington, DC WV West Virginia WI Wisconsin WY Wyoming
Zip/Postal Code
Business Phone
Other Phone
FAX
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 Claim Number:                 

 Policy Number:                 

 Insurance Company / Retaining Entity

- 21st Century Insurance A. Central Insurance Company A. I. M. Mutual AAA Mid-Atlantic Insurance Group AAA of CA, NV UT ACA Financial Guaranty Corporation Academic Health Professionals Insurance Association Accident Fund Insurance Company of America Accredited Surety and Casualty Company Ace, Limited ACSTAR Insurance Company ACUITY Adair County Mutual Admiral Insurance Adriatic Insurance Aegis Security Insurance Company Affiliated FM Insurance Company Agri General Insurance Company Agricultural Workers Mutual Auto Insurance Company Agway Insurance Company AI Pacific AIG AIU Alabama Self-Insured Workers Compensation Fund Alaska Rural Electric Cooperative Association Alberta Motor Association Alfa Insurance Algoma Mutual Insurance Company Alliance Insurance Companies Alliance Mutual Insurance Company Alliance of Nonprofits for Insurance, Risk Retention Group Allianz Allianz Canada Allianz Deutschland Allied Insurance Allmerica (P&C) Allstate Allstate Canada AmCOMP Assurance American Agents Insurance Company American Agricultural Insurance Company American Agrisurance American Commerce Insurance Company American Contractors Indemnity Company American Contractors Insurance Company American Country Insurance Company American Empire Group American Equity Insurance Company American Family Insurance American Farm Bureau American Feed Industry Insurance Company American Financial Group, Inc. American Hardware Insurance Group American Home Insurance Company American Independent Insurance Company American Interstate Insurance Company American Merchants Casualty Company American Mining Insurance Company American Modern Insurance Group American National Lawyers Insurance Reciprocal American National Property Casualty American Nuclear Insurers American Physicians Assurance Corp. American Re American Reliable Insurance Company American Resources Insurance Co. American Safety Insurance Group American Service Insurance Company American Skyline Insurance Company American Southern Insurance Company American Sterling Insurance Company American Strategic Insurance American Summit Insurance Company American Surety Company American Transit Insurance Company American Underwriters Insurance Company AMERISAFE Insurance Group Amerisure Amex Assurance Amica Amicus Mutual Amstar Insurance Company Anesthesiologists' Professional Assurance Corp. APCapital Arbella Arch Insurance Group Architects Engineers Insurance Company Argonaut Great Central Argonaut Group Argonaut Insurance Company Arkansas Title Insurance Company Armed Forces Insurance Asset Guaranty Insurance Company Associated Aviation Underwriters Associated Industries Insurance Company Associated Mutual Association Casualty Insurance Company Assurant Group Atlanta Casualty Company Atlanta Claims Association Atlantic Charter Insurance Company Atlantic Mutual Companies Attorneys Liability Protection Society Austin Mutual Insurance Group Auto-Owners Avemco Insurance Company Avomark AXA Art Insurance Corporation AXA Corporate Solutions AXA Group AXA Insurance Ayr Farmers' Mutual Badger Mutual Insurance Company Balboa Life Casualty Baldwin Lyons Group Baltimore Equitable Insurance BancInsure Bankers Insurance Group Barnstable County Mutual Insurance Company Barry Zalma, Inc. Bay Colony Insurance Company Bay of Quinte Mutual Bayside Casualty Insurance Company Beacon Insurance Group Beacon Mutual Belair Insurance Company Benchmark Insurance Company Berkley Administrators Bertie Clinton Mutual BETA Healthcare Group Bituminous Insurance Blanshard Mutual Blue Ridge Insurance Boiler Inspection Insurance Company Brant Mutual Insurance Company Bremen Farmers' Mutual Brethren Mutual Briar Creek Mutual Insurance Company British Columbia Automobile Association British Columbia Insurance Company Brotherhood Mutual Insurance Company Buckeye State Mutual Insurance Company Builders' Association Self-Insurers' Fund Builders Contractors Associations of Mississippi Self-Insurers Builders Contractors Insurance Company RRG Builders Insurance Group Builders Mutual Bunker Hill Insurance Company CAA Saskatchewan CalFarm Insurance Caliber One California Casualty California FAIR Plan California Insurance Group Cameron Mutual CAMICO Mutual Insurance Company Canada Life Casualty Canadian Millers' Mutual Insurance Company Canadian Northern Shield Insurance Company Capitol Indemnity Caradoc Delaware Mutual Insurance Company Carolina Casualty Casco Indemnity Casualty Reciprocal Exchange Cayuga Mutual Fire Insurance Company CBIA Comp Insurance Services Celina Insurance Central Insurance Companies Centre Group Century Casualty Century Surety Century-National Insurance Company Certas CGU Charter Insurance Companies Chartwell Re Chautauqua Patrons Insurance Association Chieftain Insurance Chubb Chubb Executive Risk Church Insurance Company Church Mutual Cincinnati Equitable Insurance Company Cincinnati Insurance Companies Citadel General Assurance Citizens Insurance Company Civil Service Employees Clarendon Insurance Group CNA CNA Global Resource Managers CNA Re CNA Surety Coast National Insurance Company Colonial Casualty Insurance Company Colonial Surety Colony Insurance Colorado Casualty Colorado Compensation Insurance Authority Colorado Farm Bureau Mutual Insurance Company Colorado Intergovernmental Risk Sharing Agency Colorado School Districts Self-Insurance Pool Colorado Western Insurance Company Columbia Insurance Group Commerce Industry Insurance Company Commerce Insurance Company Commercial Risk Reinsurance Company Commonwealth Insurance Company Commonwealth Medical Liability Insurance Company Commonwealth Risk Companion Property & Casualty Group CompFirst Condor Insurance Connecticut FAIR Plan Connecticut Life Casualty Connecticut Medical Insurance Company Consumers Insurance Continental Western Insurance Company Contractors Bonding and Insurance Company Co-operative Insurance Companies Copic Insurance Company Coregis Cornerstone National Insurance Company Cotton States Insurance Country Financial CPA Mutual Insurance Company Crum Forster Crusader Insurance Company Cumberland Group CUNA Mutual Direct General Discover Re Doctors Insurance Reciprocal Doctors Life Insurance Company Dodson Group Donegal Insurance Group Downie Mutual Insurance Company DPIC Dufferin Mutual Dumfries Mutual Insurance Company Eagle Insurance Group Eastern Dentists Insurance Company EBI Economical Insurance Educators Alliance Insurance Company Electric Insurance Company EMC Insurance Companies Empire Fire Marine Employers Insurance Company of Nevada Employers Re Employers Security Insurance Company Encompass Insurance Energy Insurance Mutual Enhance Financial Services Group Equity Mutual Insurance Company Erie and Niagara Insurance Association Erie Insurance Erie Mutual Fire Insurance Company Essex Insurance Company esurance EULER American Credit Indemnity Everest National Insurance Company Everest Re Group, Ltd. Everett Cash Mutual Evergreen USA Falvey Cargo Underwriters Farm Bureau of Michigan Farm Credit System Association Captive Insurance Company Farm Family Farmers Alliance Mutual Insurance Company Farmers Home Group Farmers Insurance Group Farmers Laborers Mutual Insurance Company Farmers Mechanics Mutual Insurance Co. of West Virginia Farmers Mutual Hail Insurance Company of Iowa Farmers Mutual Insurance Company Farmers Mutual Protective Association RVOS of Texas Farmers Mutual Relief Association Farmland Insurance FCCI Federated Insurance Company Federated Mutual Insurance Company Federated National Federated Rural Electric Insurance Exchange FHM Insurance Company Fidelity First Insurance Company Fidelity National Title Insurance Company Financial Guaranty Insurance Company Financial Pacific Financial Security Assurance Group Finger Lakes Fire Casualty Fireman's Fund First American Insurance Company First American Title Insurance Company First Floridian Auto Home Insurance Company First Indemnity of America First Insurance Company of Hawaii First Nonprofit Companies First Trenton Insurance Group FirstComp Insurance Company Fitchburg Mutual Insurance Company Florida Family Mutual Florida Farm Bureau Florida Lawyers Mutual Insurance Company Florida Physicians Insurance Company Florists' Mutual Insurance Company FM Global Foreign Credit Insurance Association Foremost Formosa Mutual Fire Insurance Fortune Insurance Company Foundation Reserve Insurance Company Founders Insurance Frankenmuth Mutual Franklin Mutual Insurance Frederick Mutual Freehold Mutual Fremont Compensation Fremont Mutual Friends Cove Mutual Insurance Company Frontier Insurance Fulmont Mutual Insurance Company GAINSCO Insurance Company Gateway Insurance Company GE Medical Protective Company GEICO Gem State Insurance Company General Casualty General Fire Casualty General Reinsurance Corporation General Star GeneralCologne Re Georgia Casualty Surety Georgia Underwriting Association GeoVera Insurance Company Germania Farm Mutual Germania Farmers' Mutual Germantown Mutual Insurance Company Glencoe Re Glengarry Farmers' Mutual GMAC Insurance GMAC Re GNY Insurance Companies Golden Bear Insurance Company Golden Eagle Insurance Corporation Goodville Mutual Gore Mutual Grain Dealers Mutual Gramercy Insurance Company Grange Insurance Companies Grange Insurance Group Grange Mutual Insurance Company Gray Insurance Company Great American Insurance Great West Casualty Greatland Insurance Company Green Garden Mutual Insurance Company Grenville Mutual Insurance Company Grinnell Mutual Group Grocers Insurance Guarantee Company of North America Guard Insurance Group GuideOne Insurance Gulf Insurance Group Halwell Mutual Hanover Insurance Company Harford Mutual Harleysville Group Hartford Steam Boiler Inspection Insurance Company Hastings Mutual Insurance Company Hawaii Employers’ Mutual Insurance Company Hay Mutual Insurance Company HCC Insurance Holdings Heartland Lloyds Insurance Company Heartland Mutual Highlands Insurance Group HIH Insurance Hingham Mutual Holyoke Mutual Insurance Company Home State County Mutual Homesite Insurance Company Homestead Mutual Horace Mann Insurance Housing Authority Risk Retention Group Houston Casualty Howick Mutual Insurance HSBC Canadian Direct Insurance Company Hudson Insurance Company HUM Group Humboldt Mutual Insurance Association Hurst Home Insurance Company IGF Insurance Company Illinois Insurance Exchange Illinois National Illinois Public Risk Fund IMT Insurance Independence Casualty Surety Company Indiana Farm Bureau Indiana Farmers Indiana Lumbermens Insurance Company Industrial Risk Insurers Infinity Group ING Halifax ING Western Union Injured Workers' Insurance Fund Insurance Company of the West Insurance Corporation of British Columbia Insurance Placement Facility of Pennsylvania Insurors Indemnity Company Integrity Mutual International Fidelity Insurance Company Iowa Mennonite Mutual Aid Association Iowa Mutual ISBA Mutual Insurance Company Island Insurance Companies James River Insurance Company Jewelers Mutual Insurance Company Kansas Farm Bureau Kansas Medical Mutual Insurance Company Kansas Mutual Insurance Company Kemper Kemper Environmental Kent Essex Mutual Insurance Company Kentucky Farm Bureau Kentucky National Insurance Company Key Risk Insurance Company LACE-SIF Lackawanna Casualty Lambton Mutual LAMMICO Lanark Mutual Insurance Company Lancer Insurance Company Lawyers Mutual Insurance Company Lawyers Mutual Liability Insurance Company of North Carolina Lawyer's Professional Indemnity Corp. Le Mars Mutual Leader Insurance Company Lebanon Mutual Insurance Company Legion Insurance Group LEMIC Insurance Company Liberty Canada Liberty Mutual Liberty Northwest Lincoln General Insurance Company Lititz Mutual Lloyds of London London Guarantee Insurance Canada London Reinsurance Group Louisiana Pest Control Insurance Company Lumbermen's Underwriting Alliance LWCC Madison Mutual Insurance Company Mag Mutual Main Street America Group Maine Employers' Mutual Insurance Company Majestic Insurance Company ManagedComp Insurance Company Manitoba Public Insurance Markel American Insurance Company MarketScout Markham General Insurance Company Marshall Mutual Insurance Company Maryland Automobile Insurance Fund (MAIF) Marysville Mutual Insurance Company Maxum Specialty Insurance Group MBIA McKillop Mutual Meadowbrook Insurance Group MedAmerica Mutual Risk Retention Group Medical Assurance Group Medical Liability Mutual Insurance Company Medical Mutual Group Medical Mutual Insurance Company of Maine Medical Mutual Liability Insurance Society of Maryland Medmarc Insurance Group MEEMIC Meloche Monnex Mendota Insurance Company Mennonite Aid Plan of the Pacific Coast Mennonite Mutual Fire Insurance Company Mennonite Mutual Insurance Company Merchants Bonding Company Merchants Insurance Group Mercury Insurance Meridian Insurance Met Life Miami Mutual Insurance Company Michigan Construction Industry Mutual Michigan Educational Employees Mutual Insurance Company Michigan Insurance Company Michigan Millers Mutual Insurance Company Mid-Continent Insurance Company Middlesex Mutual Assurance Company Midwest Family Mutual Midwest Mutual Insurance Company MIIX Millers First Insurance Companies Millers Mutual Millville Mutual Minnesota Surety And Trust Company Missouri Employers Mutual Insurance Missouri Valley Mutual Mitsui Sumitomo Insurance Mitsui Sumitomo Insurance Group Monroe Guaranty Montgomery Insurance Monticello Insurance Company Mortgage Guaranty Insurance Corporation Motor Club of America Motorists Insurance Group MSI Companies Mt. Washington Assurance Corporation Municipal Insurance Association of British Columbia Municipal Mutual Insurance Company Mutual Aid Association Mutual Aid Exchange Mutual Benefit Group Mutual Fire Automobile Insurance Company Mutual Fire Insurance Association of New England Mutual Fire Insurance Company of British Columbia Mutual Insurance Company of Arizona Mutual of Enumclaw Mutual of Omaha Mutual Protection Trust Mutual Reinsurance Bureau Mutual Risk Management, Ltd. NAC Re National American Insurance Company National American Insurance Company of California National Farmers Union National Flood Insurance Program National Frontier Insurance Company National Grange Mutual National Indemnity National Insurance Company National Land Title Insurance Company National Lloyds Insurance Company National Security Group National Service Contract Ins. Co. RRG National Union Fire National Warranty Insurance Company Nationwide NAU Country Insurance Company Nautilus Insurance Group Navigators Insurance Nazareth Mutual Insurance Company NCMIC Insurance Company NCRIC Group Nevada General Insurance Company New Hope Mutual New Jersey Citizens United Reciprocal Exchange New Jersey Manufacturers New Mexico Mutual Casualty Company New York Central Mutual Fire New York State Insurance Fund NLC Nodak Mutual Insurance Company Norcal Mutual Insurance Company Norfolk Mutual Insurance Company North Blenheim Mutual Insurance Company North Country Insurance Company North Kent Mutual Fire Insurance Company North Pointe Insurance Company North Star Companies North Waterloo Farmers Mutual Insurance Company Northern Neck Insurance Company Northland Insurance Companies Nova Casualty NYMAGIC Oak Casualty Insurance Company Odyssey Re OHIC Insurance Company Ohio Bar Liability Insurance Company Ohio Bureau of Workers Compensation Ohio Casualty Group Ohio Indemnity Ohio Mutual Insurance Group Oklahoma Farm Bureau Old Guard Insurance Old Lyme Insurance Company of Rhode Island Old Republic Insurance Group Old Republic Surety Company Old Republic Title Insurance Company Old United Insurance Companies Omni Insurance Group OneBeacon Ontario School Boards' Insurance Exchange Onyx Insurance Group Ophthalmic Mutual Insurance Company Optimum Farm Insurance Optimum Group Optimum West Insurance Company Oregon Mutual Orion Group Otsego Mutual Oxford Mutual Insurance Company Pacific Eagle Insurance Company Palisades Safety Insurance Association Parkway Insurance Company PartnerRe Partners Mutual Insurance Company Patrons Group Patrons Oxford Insurance Company Peel Maryborough Mutual Insurance Company Peel Mutual Insurance Company Peerless Insurance Pekin Insurance Pembridge Insurance Company PEMCO Peninsula Insurance Company Penn Mutual Insurance Company Penn National Insurance Penn-America Group Pennsylvania Lumbermens Mutual Insurance Company Pennsylvania Medical Society Liability Insurance Company Pennsylvania Millers Mutual Insurance Company Permanent General Companies Pharmacists Mutual Insurance Company PHICO Philadelphia Contributionship for the Insurance of Houses from Philadelphia Insurance Companies Physicians Mutual PIC Wisconsin PICA Group Pilot Insurance Company Pinnacol Assurance Pioneer State Mutual Insurance Company Platinum Underwriters Holdings, Ltd. Plymouth Rock Assurance Corporation PMA Insurance Group PMA Re PMI Mortgage Insurance Company Podiatry Insurance Company of America Portage Mutual Preferred Mutual Insurance Company Preferred Physicians Insurance Company Preferred Risk Mutual Premier Insurance Company Premier Insurance Exchange RRG Pre-Paid Legal Services Prescott Mutual Insurance Company Princeton Insurance Company Professional Insurance Agents Ltd Professionals Advocate Insurance Company Proformance Insurance Company Program BETA Progressive ProMutual Group Promutuel ProNational Insurance Company Providence Mutual Providence Washington Insurance Companies Prudential Public Service Mutual PXRE Re QualSure Insurance Corp. Quincy Mutual Radian Guaranty Ranger Insurance RBC Insurance Company Reciprocal Group Regis Insurance Company Reliance Insurance Company Reliant American Renaissance Re Republic Group Republic Indemnity Republic Mortgage Insurance Company Republic Western Response Insurance Restaurant Insurance Corp RLI Corp Rochdale Insurance Company Rockford Mutual Rockingham Group Rockwood Casualty Royal Sun Alliance RTW, Inc. Rural Community Insurance Company Rural Insurance Company Rutgers Casualty SAFECO Safety Insurance Company Safety National Sagamore Insurance Company SAIF Corporation Saucon Mutual SCOR Re Scottsdale Insurance Company SCPIE Secura Insurance Security Indemnity Insurance Company Security Mutual Insurance Company Seibels Bruce Group Selective Insurance Sentry Insurance Sequoia Insurance Company Shelter Insurance Sierra Insurance Group Signal Mutual Society Insurance Sompo Japan Insurance Company of American South Carolina Farm Bureau South Carolina Wind Hail Underwriters Association South Easthope Mutual Insurance Company SouthEastern Mutual Insurance Company Southern Farm Bureau Casualty Southern General Southern Guaranty Insurance Company Southern Michigan Insurance Company Southern Mutual Southern Mutual Church Insurance Company Southern Trust Insurance Company Southern United Southwest Casualty Company Spring Valley Mutual Standard Mutual Insurance Company State Auto Insurance State Compensation Insurance Fund State Farm Insurance State Fund State Fund Mutual State Industrial Insurance System State National Insurance Companies State Volunteer Mutual Insurance Company States Self-Insurers RRG Statewide Insurance Company Sterling Insurance Company Stewart Title Guaranty Company Sublimity Insurance Company Sugarcreek Mutual Sumitomo Marine Fire Insurance Company Superior Insurance Group Superior National Insurance Company Sutter Insurance Company Swiss Re T.H.E. Insurance Company Technology Insurance Company Tennessee Farmers Tennessee Insurance Company Texas Builders Insurance Company Texas Farm Bureau Insurance Companies Texas Lawyers’ Insurance Exchange Texas Medical Insurance Company Texas Mutual Insurance Company The American Club The Bar Plan Mutual Insurance Company The Co-operators The Dentists Insurance Company The Doctors Company The Green Tree Perpetual Assurance Company The Hartford Insurance Company The Markel Companies The Personal The Philanthropic Insurance Companies The Virginia Insurance Reciprocal TIG Toa Re Tokio Marine Topa Insurance Company Tower Group Companies Townsend Farmers' Mutual Fire Insurance Company Transamerica Reinsurance Transatlantic Re Transguard Insurance Company Trenwick Group Triad Guaranty Insurance Triangle Companies Trinity Universal Tri-State Consumer Insurance Company Ulico Casualty Unigard Union Insurance Company Union Mutual Insurance Company Union Standard Insurance Company United Casualty Surety United Educators United Fire Group United National Group United States Liability Insurance Group United States Surety Company Universal Insurance Company Universal Underwriters Upland Mutual Insurance Company USAA USAIG USAU Usborne Hibbert Mutual Fire Insurance Company Utah Medical Insurance Exchange Utica First Insurance Company Utica National Vanliner Insurance Company Verlan Fire Insurance Company Vermont Mutual Vesta Fire Insurance Veterinary Pet Insurance Company Victor O. Schinnerer Co., Inc. Victoria Insurance Company Vinland Town Mutual Virginia Farm Bureau Virginia Mutual Insurance Company W. R. Berkley Company Wabisa Mutual Insurance Company Wall Rose Mutual Insurance Company Wasatch Crest Group Water Quality Insurance Syndicate Wausau Insurance Wawanesa Mutual Insurance Company West Bend Mutual West Elgin Mutual Insurance Company West Virginia Bureau of Employment Programs West Virginia National Auto Insurance Company West Wawanosh Mutual Insurance Company Westcor Land Title Insurance Company Western General Group Western Insurance Company Western Mutual Insurance Company Western Mutual Insurance Group Western National Insurance Group Western Protectors Insurance Company Western Reserve Group Western Specialty Insurance Company Western World Insurance Group Westfield Companies Westminster Mutual Insurance Company Westport Insurance White Mountain Insurance Group Wilson Mutual Windsor Group Winterthur Group Wisconsin Lawyers Mutual Insurance Company Wisconsin Mutual Wisconsin Reinsurance Corporation Wm. H. McGee Wolverine Mutual Workers Compensation Fund of Utah Workers Compensation Reinsurance Association Workers Compensation Self-Insurance Trust Workmen's Auto Insurance Company Zenith National Zurich North America Zurich Personal

If Company is not listed, enter it here

 

Insured's information:

Name
Home Phone
Work Phone
Cell Phone
Loss Address
Address (cont.)
City
State/Province	State AL Alabama AK Alaska AZ Arizona AR Arkansas CA California CO Colorado CT Connecticut DE Delaware FL Florida GA Georgia HI Hawaii ID Idaho IL Illinois IN Indiana IA Iowa KS Kansas KY Kentucky LA Louisiana ME Maine MD Maryland MA Massachusetts MI Michigan MN Minnesota MS Mississippi MO Missouri MT Montana NE Nebraska NV Nevada NH New Hampshire NJ New Jersey NM New Mexico NY New York NC North Carolina ND North Dakota OH Ohio OK Oklahoma OR Oregon PA Pennsylvania RI Rhode Island SC South Carolina SD South Dakota TN Tennessee TX Texas UT Utah VT Vermont VA Virginia WA Washington DC Washington, DC WV West Virginia WI Wisconsin WY Wyoming
Zip/Postal Code

This property is:   no input Owner Occupied Tenant Occupied Vacant

 

 

Tenant Information

Name
Home Phone
Work Phone
Cell Phone

 

 

 Loss Information:

 

      Date of Loss:  -- mm/dd/yy

 Approx. Time of Loss:  

   Type of  Loss:    Residential Structure Commercial Structure Airplane Automotive Industrial Marine Nonstructural Other... See Notes

 Contact person to gain access: Insured Open…Go Tennant Prop Mgmt. On Site Mgmt. See Contact Notes

 Additional Notes

 

Once we complete our Fire Investigation a full report will be emailed to you.