Lotus Insurance Solutions, LLC
Casualty Investigation

  • Please provide as much information about the claim as possible
  • Required fields are marked by the symbol
  • If you do not have the information for a required field, please enter "unknown"
  • 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
    Loss Location Information
    Address City State Zip Code
    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