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  Welcome!
Attention:
Policy Number:
Your Name:
Contact Person:
Whom should the adjuster call to settle your claim?
Name:
Home Phone:
Work Phone:
E-Mail:
Best time to call:
Authority Contacted:
Police/Fire Dept. Name:
Police/Fire Dept. Phone:
Report number:
Claim Information:
Date of loss:
Location of claim:
Cause of loss:
Describe Your Damages/Loss:
Emergency services needed: Temporary Shelter Required? Yes  No
Windows Required Boardup?
Yes  No
Other?:                  
Persons Injured:
Name/address
Phone number:
Type of injuries:
Cause of injuries:
Comments and/or
Other Information:
             

 
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Toll Free: 1-800-967-7065    Phone: (330) 494-8400    Customer Service