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Dynamic Claims Services, Inc.™
Causality Investigation
Please provide as much information about the claim as possible.
Required fields are marked by the * symbol and must be completed in order to process your request. If required fields are not completed in full, submission of form may take you to an error page. Your information will not be saved and will have to be reentered.
If you do not have the information for a required field, please enter "unknown".
Claim Details and Assignment Type
DOL (mm/dd/yyyy)
*
Must be entered in a mm/dd/yyyy format.
Claim #
*
Please enter the claim number.
Policy #
*
Please enter the Policy number for this claim.
Claim Type
*
Auto Liability
General Liability
Workers' Compensation
Other
Description of Loss
*
Please enter a description of loss.
Assignment Type
*
Limited Assignment
Full Assignment
General Assignment Instructions
*
Please describe the details of work you would like for us to preform on this claim.
Special Instructions for Statements/Interviews (optional below).
Insured
*
Do Not Contact
Interview Only
Recorded Statement
Written Summary
Include Summary
In-Person
Phone
Claimant
*
Do Not Contact
Interview Only
Recorded Statement
Written Statement
Include Summary
In Person
Phone
Witness
*
Do Not Contact
Interview Only
Recorded Statmenet
Written Statment
Include Summary
In Person
Phone
Client's Information/Reporting Address
Client Company Name
*
Name of Company is required.
Report to:
*
First
Last
First and Last name required.
Mailing Address
*
Line 1
Line 2
City
State
Zip Code
Country
Mailing address is required of all new clients or new locations of current clients.
Phone Number
*
-
-
Must be entered in a xxx-xxx-xxxx format. If this is an international number, please enter details in the General Assignment Instructions field.
Secondary Number
*
-
-
Fax Number
*
-
-
Email
*
Insured's Name and Contact Information
Name
*
First
Last
Company Name
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Phone Number
*
-
-
Secondary Number
*
-
-
Fax Number
*
-
-
Email
*
Instructions/Other Information Regarding Insured
*
Claimant's Information - Primary
Claimant Name
*
First
Last
Company Name
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Email
*
Phone Number
*
-
-
Secondary Number
*
-
-
Fax Number
*
-
-
Instructions or Other Information Regarding the Primary Claimant
*
Are there Additional Claimants or other Parties Involved?
*
Yes
No
Upload File
*
Max file size: 20MB
Upload File
*
Max file size: 20MB
Upload File
*
Max file size: 20MB
