Forensic Accounting Assignment Form

Your preference will be taken into consideration based on availability and type of claim / case

Who is the calculation on behalf of (e.g., insured, claimant, other)?*

Insured:

Claimant:

Date of Loss:

Loss Location

End of Loss Period (if known):

Claim, Policy or File Number: *

Amount(s) Claimed: *

Event Giving Rise to Claim:

Service Requested:

Contact Person & Telephone Number at Insured's, Claimant's, Plaintiff's, or Defendant's Office:

Contact Person Email Address at Insured's, Claimant's, Plaintiff's, or Defendant's Office:

Coverage limitations

(e.g., waiting period, coinsurance, deductibles)

Provide coverage limitations:

Adjuster or Attorney Name: *

Email Address: *

Adjuster or Attorney Telephone Number: *

Company Name:

Street Address:

Address Line 2:

City:

State / Zip:

Miscellaneous Information & Comments:

How did you hear about our services? *

New code

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MarksNelson is now Springline Advisory