ASG Adjusters

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Claim Assignment

Fill out the form below and click submit. You will receive a claim acknowledgement when the claim is set up and assigned to an adjuster.

Submit a Claim for Motor Vehicle

Choose One of Four ways to submit a claim

1. Click Here to submit a claim via your own email program.

2. If you have a completed Loss Form, you can send it to our Fax Line: 713-680-2371.

3. If you have a completed Loss Form ready to submit, you may upload it here and send it without filling out the rest of the form.

Upload claim assignment or any additional attachments:

4. Or you can just fill out the form below

*Required Fields

Contact Information
*First Name:
*Last Name:
Phone Number:
Fax Number:
*Email:

Submit By Company

Customer Number:
First Name:
Last Name:
Company Name:
Address:
City:
State:
Zip Code:
Contact Phone Number:
Contact Fax Number:
Contact Email:

Policy Information

Policy Number:
Policy Effective Date:

Loss Information

Date of Loss:
Cusomter Claim #:
Location of Loss:
Description of Loss:
Were Police called:
Was a Ticket Issued:
Name of Police Dept:

Insured Information

Insured Person / Company:
Contact First Name:
Contact Last Name:
Insured Address:
City:
State:
Zip Code:
Insured Home Phone:
Insured Work Phone:

Insured Vehicle Information

Vehicle Plate / Tag Number:
Vehicle Make:
Vehicle Model:
Vehicle Vin:
Driver's First Name:
Driver's Last Name:
Driver's Home Phone:
Driver's Work Phone:
Damage Description:
Is Car Driveable:
If not, where is vehicle:
Injured Party First Name:
Injured Party Last Name:
Description of Injury:

Claimant Information

Claimant First Name:
Claimant Last Name:
Claimant Address:
City:
State:
Zip Code:
Claimant Home Phone:
Claimant Work Phone:

Claimant Vehicle Information

Vehicle Plate / Tag Number:
Vehicle Make:
Vehicle Model:
Vehicle Vin:
Driver's First Name:
Driver's Last Name:
Driver's Home Phone:
Driver's Work Phone:
Damage Description:
Is Car Driveable:
If not, where is vehicle:
Injured Party First Name:
Injured Party Last Name:
Description of Injury:

Witness Information

Claimant First Name:
Claimant Last Name:
Claimant Address:
City:
State:
Zip Code:
Claimant Home Phone:
Claimant Work Phone:

Special Instructions:

If you have any additional attachments please attach them in section two at the top of this form.