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  Welcome!
Attention:
Type of Policy:
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:
Date of loss:

Description of Loss:

Comments and/or Other Information:
             

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