To submit a new case assignment, please complete the form below. You can send the form electronically to us by filling in the detailed information and clicking the submit button. As an alternative, you can complete the form, print it, then mail or fax it to us at:

Brickerhaven Consulting Group
531 46th Avenue
San Francisco, California 94121
Telephone (415) 387-2500
YOUR CONTACT INFORMATION
Email Address (required)
Your Name
Company 
Title
Mailing Address
City State Zip
Telephone Number - Ext
Billing Address, if Different (use commas to separate)
CASE ASSIGNMENT INFORMATION
File Name
Date of Loss/Discovery/Incident
Your File/Claim Number
Suspension Period Dates
 
to
Category of Loss
Type of Loss
POLICY LIMIT INFORMATION
Loss
Type
Monthly Sub-Limit
Co-Insurance
Deductible
Form Number
Type
Limit
Monthly Sub-Limit
Co-Insurance
Deductible
Form Number
CLAIMANT/CONTACT INFORMATION
Name
Home Phone  - 
Work Phone - Ext  
Street
Apt/Box
City State Zip
LOSS LOCATION INFORMATION IF DIFFERENT THAN ABOVE
Telephone Number - Ext
Street
Apt/Box
City State Zip
ACCOUNTANT/BOOK KEEPER CONTACT
Name
Telephone Number - Ext
Street
Apt/Box
City State Zip 

COMMENTS

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