Spikes-Braniff and Associates
Liability Investigation Form

Claim Details and Assignment Type
response required DOL(mm/dd/yyyy)
response required Claim #
Policy #
response required Claim Type
Auto Liability
General Liability
Product Liability
Workmans Comp
Other
response required Description of Loss
response required Assignment Type 
Limited Assignment
Full Assignment
response required General Assignment Instructions 
Special Instructions for Statements/Interviews (optional below) 
  Do Not ContactInterview OnlyRecorded StatementWritten StatementInclude SummaryIn-PersonPhone
Insured
Claimant
Witnesses
Client Information/Reporting Address
response required Client Company Name
response required First Name
response required Last Name
response required Mailing Address
Building/Suite
response required City
response required State
response required Zip
response required Phone #
Fax #
response required E-Mail Address
Insured Name and Contact Information:
response required Insured First Name
Middle
response required Last Name
Company Name
Address 1
Address 2
City
State
Zip
response required Phone #
Other Phone #
Fax #
Instructions/Other Information Regarding Insured
Claimant Information - Primary
response required Claimant First Name
Middle
response required Last Name
Company Name
Address 1
Address 2
City
State
Zip
response required Phone #
Other Phone #
Fax #
Instructions/Other Information Regarding The Primary Claimant
response required Are There Additional Claimants and/or Other Parties Involved? Yes No