Assignment

BOB KINDER & SON, INC. ASSIGNMENT FORM

1. Insurance Company		Reported By
2. Report To		Telephone Number
3. Policy Number		Effective Dates
4. Claim Number		Contract Number
5. Date of Loss		Email Address
6. Assured		Telephone Number
7. Owner/Operator		Telephone Number
Address 1
Address 2
8. Unit Number		Vehicle (Year Make Model Serial #)
9. Stated Amount		Deductible
10. Type of Loss	Comprehensive Theft Collision Fire
11. Drive Info & Age
12. Scene of Loss
13. Loss Description
14. Location of Unit
15. Investigative Authority
16. Lien Holder
17. Unit Leased
18. Company Request	PhotosAppraisalA.C.V.Police ReportSubrogationIssue ProofSell SalvageStatement
19. Notes