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Report a claim Form
Name:
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Policy #:
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Date loss occurred:
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Cause of Loss:
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Burglary
Civil Commotion
Damage by Burglars
Earthquake
Explosion
Falling Objects
Fire
Flood
Hail
Ice
Lightning
Liability – Body Injury
Liability – Med Pay
Liability – Property
Damage
Mischief & Vandalism
Other
Owner/Lia/Tenant Lia
Plane – Aircraft
Power Surge
Smoke
Snow
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Vehicle Damage
Volcanic Eruption
Water Damage
Wind
Phone:
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Email Address
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Description:
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Address of damaged building/property
Street Address
Apartment, suite, etc
City
State/Province
ZIP / Postal Code
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Agency Download Form
Agency Information
Agency Code
*
Agency Name
*
Street Address
Apartment, suite, etc
City
State/Province
ZIP / Postal Code
Phone:
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Email Address
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Contact
Name
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Phone:
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Email Address
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Agency Management System
Vendor Name
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Version
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IVANS Information
IVANs Y Acct #
*
IVANS UserID
*
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