CLAIMS SERVICES INC.
TASK MANAGEMENT FORM
TELEPHONE:
(310) - 713-2190
FAX:
(714) - 908-1715
Please Enter All Pertinent Information Below:
Information provided is for use by JCLE and will not be sold or distrubuted to any other party.
FIELDS MARKED WITH * DENOTES REQUIRED FIELDS.
* CLIENT NAME:
* TELEPHONE:
EXTENSION:
FAX:
INSURED:

DATE OF INCIDENT:

CLAIM #:
PLEASE PERFORM TASK(S) CHECKED
Face to face recorded statement: Insured: Claimant: Witness:

NAME:

ADDRESS:
TELEPHONE:
Face to face recorded statement: Insured: Claimant: Witness:

NAME:

ADDRESS:
TELEPHONE:
Face to face recorded statement: Insured: Claimant: Witness:

NAME:

ADDRESS:
TELEPHONE:
Face to face recorded statement: Insured: Claimant: Witness:

NAME:

ADDRESS:
TELEPHONE:
Obtain Police Report:
Photograph and Diagram of the Accident Scene:
Auto Damage Appraisal
Clinic Inspection and Copy of Medical Records:

NAME:

ADDRESS:
TELEPHONE:

OTHER ACTIVITY:

CLICK TO SUBMIT: CLICK TO CLEAR:
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