Assignment Form

Northern Illinois Auto Adjustments Inc.

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Northern Illinois Auto Adjustments Inc.

Claim Information:

Insurance Company

Adjuster

Insurance

Date of Loss

Assignment Type

Claim For

Type of Loss

Type of Claim

Unit Type

Owner Information:

Business Name

Owner/Contact

Address

City

State

Zip Code

Phone

Email Address

Vehicle Location:

Vehicle Location

Loacation

City

Zip Code

State

Vehicle Information:

Vehicle

Make

Model

Identification

Damage / Facts of Loss

Instructions

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