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Claim & Assignment Details
Claim Number
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Policy Number
Initial Report Due
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15 Days
10 Days
7 Days
5 Days
Assignment Level
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Appraisal Only
Full Adjustment
Date of Loss
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MM slash DD slash YYYY
Type of Loss
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Earthquake
Fire/Smoke
Flood
Theft
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Vehicular Collision
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Cat #
Loss Location
Loss Location Address
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ZIP Code
Insured's Name
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Insured's Address
Street Address
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ZIP Code
Insured's Contact Person
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Phone
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Alternate Phone
Claimant
Phone
Alternate Phone
Facts of Loss (Description)
Assignment Instructions
Coverage Information
Dwelling Coverage
Other Structures
Contents Coverage
Loss of Use
Deductable
Building Coverage
Building Deductable
Building Contents Coverage
Building Contents Deductable
Additional Coverage or Endorsements
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