Rimkus Consulting Group: 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:

Inspection Contact Name:

Inspection Contact Phone Number:

Location Of Occurrence:

City: State: Zip Code:

Description:
WHAT?
WHERE?
WHEN?
ETC.

Services Requested from Rimkus

(Please Check Box)

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

INVOICING INFORMATION:

Invoice To:

Company:

Telephone:

Address:

City:

State: Zip Code: