Insurance claims assuranc
H.G.Busby & Associates
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H .G .BUSBY & ASSOCIATES
Please fill out the following form to report a new assignment. If you have any questions, please
call us at 770.552.7220 or 800.686.0636. You may also contact Harvey Busby directly at 770.356.4317.
Please Enter As Much Information As Possible
Mr. or Ms. ( please choose a Salutation.)
Client's First Name:
Client's Last Name:
Client Company Name:
Client Company Mailing Address:/ Street Address or Post Office Box:
Client Telephone Number:
Client Fax Number:
Client Email Address:
How do you prefer that we communicate with you? ( please choose one.) 1. Email reports and letters, 2. Fax all reports and letters, 3. Mail reports and letters, 4. Email and Mail reports and letters, 5. Mail Only or 6. Email Only.
ASSIGNMENT INFORMATION: Insuredís Name (i.e., Business name or named insured) or Case Name (e.g., ABC Company vs. XYZ Company):
Claim Number or Case Reference Number:
Date of Loss:
Cause of Loss:
Restoration Period: from date to date
Comments regarding restoration period or other specific conditions to be considered:
(General Instructions): Type of Claim and Services to be Performed: ( please choose one.) 1. Calculate Business Income Loss, 2. Calculate Stock Loss, 3. Verify Valuation of Business Personal Property, 4. Review Employee Dishonesty Claim, 5. Evaluate Financial Condition, 6. Provide Litigation Support, 7. Business Valuation, 8. Other Services
Please provide any additional assignment instructions or other comments here:
Time sensitive: Do you want to designate a deadline: If yes, please indicate due date:
POLICYHOLDER INFORMATION: Contact Personís Name (Named insured or Designated Representative):
Contact Personís Mailing Address:
Street Address or Post Office Box:
Contact Personís Telephone Number:
Loss Location, if different than Mailing Address:
Does the business operate from more than one location? ( please choose one.) Yes, or No.
POLICY INFORMATION AND REVIEW INSTRUCTIONS:/ Description of Coverage:
Monthly Coverage Limit
if yes, monthly limit amount:
Aggregate Coverage Limit
Ordinary Payroll Coverage: ( please choose one.) 1. Yes, ordinary payroll is covered, or 2. No, ordinary payroll is excluded.
Is Ordinary Payroll Coverage Limited to a specific period? ( if yes, please choose one of the following.) 1. 90 days, 2. 180 days, 3. other
Coinsurance Provision: Yes, or No
Do you want us to evaluate the coinsurance Condition: Yes, or No
If yes, Coinsurance Percentage:
For Coinsurance purposes Policy Period, from date to date
OTHER: Please provide any comments you have or questions that you would like for us to address immediately here:
Thank you for your consideration. I greatly appreciate your business.
Harvey G, Busby Jr.
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