About | National Subrogation Services, LLC (NSS)

New Assignment Form

Client Name:

Claim Number:

Policy Number:

Date of Loss:

Insured Name:

Insured Company Name:

Insured Phone:

Insured Fax:

Insured Email:

Loss Address 1:

Loss Address 2:

Loss City:

Loss State:

Loss Zip Code:

Description of Loss:

Line of Business:

Claim Amount PTD:

Deductible Amount:

Reserve Amount:

Insured Address:

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Only Necessary if Different from Loss Address

Insured Adddress 1:
Insured Address 2:
Insured City:
Insured State:
Insured Zip Code:

Adverse Name:

Adverse Party Address:

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Adverse Address 1:
Adverse Address 2:
Adverse City:
Adverse State:
Adverse Zip Code:
Adverse Phone:
Adverse Fax:
Adverse Email:

Adverse Insurer Information:

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Adverse Insurer Individual Name:
Adverse Insurer Company Name:
Adverse Insurer Address 1:
Adverse Insurer Address 2:
Adverse Insurer City:
Adverse Insurer State:
Adverse Insurer Zip Code:
Adverse Insurer Phone:
Adverse Insurer Fax:
Adverse Insurer Email:
Adverse Insurer File Number:
Adverse Insurer Policy Number:

Assigning Adjuster Name:

Adjuster Address1:

Adjuster Address2:

Adjuster City:

Adjuster State:

Adjuster Zip:

Adjuster Phone:

Adjuster Fax:

Adjuster Email:

Branch Office:

Independant Adjuster Information:

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Independant Adjuster Name:
Adjuster Address1:
Adjuster Address2:
Adjuster City:
Adjuster State:
Adjuster Zip:
Adjuster Phone:
Adjuster Fax:
Adjuster Email:

Specially Retained Expert Information:

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Expert Name:
Expert Address1:
Expert Address2:
Expert City:
Expert State:
Expert Zip:
Expert Phone:
Expert Fax:
Expert Email:

Additional Information:

Physical File Delivery Method:

Please remember to send Accord, all Investigation, Proof of Damages, Proof of Payment and all file Notes. You can attach them by choosing Email from the Physical File Delivery selection box, or by sending mail/fax to the address below. Please be sure to include the claim number in the subject field.

National Subrogation Services
350 Jericho Turnpike, Ste. 310
Jericho, NY 11753
(516) 949-3620
(516) 949-3621 fax