Welcome to Norfield Associates Electronic Assignment Submission page.  To submit a new assignment, please complete the information below.  Once your information has been submitted, it will be sent to the appropriate Norfield Associates office for processing and handling.  Thank you for assigning this claim to Norfield Associates, Inc.!

CLIENT INFORMATION:  
Company Name
Street Address
City
State
Zip Code
Contact and Title
Email Address
Telephone #
   
POLICY INFORMATION:  
Your Claim Number
Policy Number
Effective Dates of the Policy
Policy Limits
   
INSURED INFORMATION:  
Insured Name
Address
City
State
Zip Code
Home Telephone Number
Work Telephone Number
Cellular Telephone Number
Insured Operator Name (if applicable)
Insured Operator Address
City
State
Zip Code
Home Telephone Number
Work Telephone Number
Cellular Telephone Number
Insured Vehicle
Vehicle Registration Number
Damage

Estimate of Repair

Date of Birth

Social Security Number

Were they injured?
   

LOSS INFORMATION:

  

Date of Loss

Time of Loss

Location of Loss;  City, State, Zip Code

Briefly Describe the Loss
   

CLAIMANT/INJURED PARTY INFORMATION:

  
Name
Address
City
State
Zip Code

Home Telephone Number

Work Telephone Number

Cellular Telephone Number

Claimant Attorney Name
Address
City
State
Zip Code

Telephone Number

Claimant Vehicle
Vehicle Registration Number

Damage

Estimate of Repair

Date of Birth

Social Security/Drivers License Number
Injuries

Medical Provider Name

Street Address
City
State
Zip Code

Telephone Number
Adverse Carrier Name and Telephone Number

Adverse Carrier Claim/Policy Number
   

OTHER INFORMATION:

  
Are there any Witnesses to the Loss?

Witness Name
Address
City
State
Zip Code

Home Telephone Number

Work  Telephone Number

Cellular Telephone Number
   

PLEASE INCLUDE THE INVESTIGATION YOU WOULD LIKE US TO CONDUCT
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