Accident Recon Inc

Accident Recon Inc. - New Assignment

Upon completion of this form, please call 405.324.5944 to advise us of your assignment submission and ensure the most immediate response possible. Thank you.

Please enter as much information as possible into the following form.

Basic Information

Your Name:	Job Title:
Company Name:
Address:
City:	State: Zip Code:
Email:
Phone:	Fax:

Assignment Information

Date of Occurrence:

Your Client Name:

Adverse Party:

Location of Occurrence

Address of Occurrence:
City: State: Zip:

Description:

Please check this box if you have additional information to email regarding this assignment.

Invoicing Information

Invoice To:
Company:	Telephone:
Address:
City:	State: Zip Code:
Claim #:	Style of Case:

Notice - Filling out this form does not constitute an acceptance or retention of services. Retention of a claim must be approved by Accident Recon Inc. senior personnel.

Upon completion of this form, please call 405.324.5944 to advise us of your assignment submission and ensure the most immediate response possible. Thank you.

Please enter the verification number in the field below.
Verification Number: