User Option - Bingham Services Inc

SUBMIT AN ASSIGNMENT

To submit an assignment for Bingham Services Inc., fill out this form and a representative will be in touch within 24 hours.

Your Company:(Required)

Your Name:(Required)

Your Phone:(Required)

Your Email:(Required)

Insured Company Name:(Required)

Insured Contact Name:(Required)

Insured Contact Phone :(Required)

Insured Contact Email Address:(Required)

Date of Loss:(Required)

Claim Number:(Required)

Loss Address:(Required)

Street Address City ZIP / Postal Code

Loss State(Required)

Adjuster Company Name:(Required)

Adjuster Contact Name:(Required)

Adjuster Address Street:(Required)

Street Address City ZIP / Postal Code

Adjuster State(Required)

Adjuster Phone:(Required)

Adjuster Email:(Required)

Notes / Special Instructions:

Upload claim documents below

Drop files here or

Max. file size: 300 MB.