BR Fitz Company New Assignment Request FormDate of Referral: November 22, 2024
 

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Insured Contact Information

 
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Yes No Unknown
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Claimant Information

 
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Yes No
 

Authorization

 
 

Type of Assignment (Check All That Apply)

 
 

This form uses a secure server to send unecrypted email. Please be aware that e-mail communication can be intercepted in transmission or misdirected. Please consider communicating any sensitive information by telephone, fax, or mail.