Submit An Assignment

Submit An Assignment...............................................Rimkus Consulting Group, Inc.

Field Names in RED Are Required Fields.

Your Name:

Your Title:

Company Name:

Address:

City:

State: Zip Code:

Email:

Telephone: Fax:

Claim No./
Insured/
Docket:

Date Of Occurrence:

Your Client:

Adverse Party:

Location Of Occurrence:

City: State: Zip Code:

Description:
WHAT?
WHERE?
WHEN?
ETC.

Services Requested from Rimkus

(Please Check Box)

Accident Reconstruction	Limited Mechanical Inspection
Site Visit	Biomechanical Evaluation
Full Mechanical Inspection	Fire Cause and Origin
Other (Please Describe)

INVOICING INFORMATION:

Invoice To:

Company:

Telephone:

Address:

City:

State: Zip Code: