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Assign A Claim

Date of Assignment
Company Assigning Loss
Company Address
Company City, State, Zip , ,
Company Phone Number
Company Contact Person
Contact Email
Insured Name
Insured Address
Insured City, State, Zip , ,
Insured Home Phone
Insured Business Phone
Claimant Name
Claimant Address
Claimant City, State, Zip , ,
Claimant Home Phone
Claimant Business Phone
Claimant's Attorney Phone Number
Date of Loss
Type of Loss
Location of Loss
Description of Loss
Policy Information
Policy Number
Policy Effective Dates to
Claim Number
Coverage Information:
Coverage A

Coverage B
Appurtenant Private Structures

Coverage C
Unscheduled Personal Property
Coverage D
Additional Living Expenses
Special Instructions